PATIENT REGISTRATION FORM

APPOINTMENT DATE:

TIME:

DOCTOR:

PATIENT INFORMATION

Legal name as printed on driver's license (please print) What name do you prefer to go by:

LAST:

FIRST:

MIDDLE:

ADDRESS:

Phone: May we leave confidential messages?

Yes No

Home:

Cell:

Work:

BIRTH DATE:

Social Security #:

GENDER AT BIRTH:

M F

Email:

Language:

English Other:

Occupation:

Race- Other:

Non-English Language:

Primary Care Physician Name:

Office Phone #:

Office Fax #:

Referring Doctor (if other than primary):

Office Phone #:

Office Fax #:

Pharmacy:

Phone #:

Location:

Name of Emergency Contact:

Phone #:

Relationship to patient:

AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION

Name:

Relation:

Phone #:

Name:

Relation:

Phone #:

INSURANCE INFORMATION

PLEASE PRESENT INSURANCE CARDS*** THEY WILL NEED TO BE SCANNED

PRIMARY INSURANCE:

GROUP#:

CONTRACT #:

SUBSCRIBER:

BIRTH DATE:

SECONDARY INSURANCE:

GROUP#:

CONTRACT #:

SUBSCRIBER:

BIRTH DATE:

*If required please put in the Referral/Insurance Auth:

RELEASE OF INFORMATION

PRIVACY STATEMENT: We protect our patient's information and the records that we have about their health and the services received in our office. We must have your written, signed consent in order to disclose your health information for the purposes of your treatment, the payment of bills, appointment reminder, etc. I have received a copy of the Privacy Notice (HIPPA-164.520). If we refer our patients to another provider or specialist, we may need to share your information with them. Your privacy is protected as only minimum information is shared.

FINANCIAL RESPONSIBILITY: I authorize the release of medical information to insurance carriers concerning my illness and treatment and I hereby Assign to the doctor all payments for medical services rendered to me or my dependent. I understand that I am responsible for any amount not covered by insurance and that I will pay any copay on the date of services rendered unless other arrangements are made.

Patient/Guardian Signature:

Date:

MEDICARE AUTHORIZATION: I request that payment of authorized Medicare benefits be made to Flint Gastroenterology Associates, PC on my behalf. I authorize the holder of my medical information to release to the HCFA and their agents any information needed to determine these benefits for related services. I understand that HFCA is the government Medicare Agency.

Medicare Beneficiary Signature:

Date:

PT REVIEWED:

Date:

Patient Questionnaire

Review of Systems - Please check any current problems/symptoms that apply

Constitutional

Fever

Chills

Night Sweats

Generalized Weakness

Weight Loss

Weight Gain

Feeling Tired/Sluggish

Trouble Sleeping

Other:

Musculoskeletal

Back Pain

Joint Pain

Limb Pain

Muscle Pain

Neck Pain

Muscle Weakness

Joint Stiffness

Joint Swelling

Other:

Eyes

Eye Pain

Blurred Vision

Double Vision

Glaucoma

Dryness

Eyesight Problems

Corrective Lenses

Eye Redness

Other:

Skin

Skin Rash

Skin Lesion

Skin Wound

Itching

Dry Skin

Eczema

Change in Color of Skin

Change in Hair

Other:

Cardiovascular

Slow Heart Rate

Fast Heart Rate

Chest Pain

High Blood Pressure

Lightheadedness

Palpitations

Angina

Swelling of Legs

Other:

Respiratory

Shortness of Breath (at rest)

Shortness of Breath (on exertion)

Wheezing

Chest Tightness

Sleep Apnea: Uses CPAP - or- Does not use CPAP

Cough

Cough with Mucus

Cough with Blood

Other:

Hematologic/Lymphatic

Anemia

Bruises Easily

Bleeds Easily

Clotting Disorder

Swollen Lymph Nodes

Night Sweats

Pale

Other:

Genitourinary

Nocturia (going at night)

Dysuria (painful urination)

Difficulty Urinating

Blood in Urine

Urine Frequency

Incontinence

Other:

Gastrointestinal History

What is your chief problem/concern?

How long have you had this problem?

Have you ever had a colonoscopy?

Yes No

When?

Performing Doctor:

Have you ever had an EGD/upper scope?

Yes No

When?

Performing Doctor:

Have you had any recent radiology exams (ultrasound, CT, MRI, or x ray)?

Have you had any recent lab work completed?

Medical History - Please check any of the medical conditions for which you have seen a doctor.

None

Anemia

Anxiety Disorder

Arthritis

Osteoarthritis

Rheumatoid

Asthma

Celiac Disease

Colon Polyps

Congestive Heart Failure

COPD

Coronary Artery Disease

Crohn's Disease

Dementia/Alzheimer's

Depression

Diabetes

Diverticular Disease

Diverticulitis

Diverticulosis

Emphysema

Esophageal Disease

Barrett's Esophagus

Varices

Fibromyalgia

Gallstones

Glaucoma

Heart Attack

Heart Valve Disease

Heart Arrhythmias

Atrial Fibrillation

Tachycardia

Bradycardia

SVT

Hemorrhoids

Hepatitis/LiverDisease

Cirrhosis

Hepatitis A

Hepatitis B

Hepatitis C

Jaundice

Other

Surgical History - Please check any of the surgeries that you have had.

None

Appendix Removal

Back Surgery

Carpal Tunnel Release

Colon Surgery

Colectomy

Partial Colectomy

Colostomy

Ileostomy

C-Section

Feeding tube

G tube

J tube

Joint Replacement/Joint Surgery

Hip Replacement

Knee Replacement

Shoulder Replacement

Joint Surgery

Plase specify

Laparoscopy (abdominal)

Liver Biopsy

Lung Surgery

Mastectomy Surgery

Prostate

Small Bowel Resection

Throat/Mouth Surgery

Tonsillectomy

Adenoidectomy

Wisdom Teeth

Other

Thyroidectomy

Transplant

Tubal Ligation

Other

FLINT GASTROENTEROLOGY ASSOCIATES, PC

Patient Questionnaire

Last:

First:

Middle:

Family Medical History

Add Family Member

Crohn's Disease

Father

Mother

Children

Brother

Sister

Other

Other Relatives

Esophageal Cancer

Father

Mother

Children

Brother

Sister

Other

Other Relatives

Kidney Cancer

Father

Mother

Children

Brother

Sister

Other

Other Relatives

Liver Cancer

Father

Mother

Children

Brother

Sister

Other

Other Relatives

Liver Disease

Father

Mother

Children

Brother

Sister

Other

Other Relatives

Ovarian Cancer

Mother

Children

Sister

Other

Other Relatives

Pancreatitis

Father

Mother

Children

Brother

Sister

Other

Other Relatives

Stomach Cancer

Father

Mother

Children

Brother

Sister

Other

Other Relatives

Ulcerative Colitis

Father

Mother

Children

Brother

Sister

Other

Other Relatives

Uterine Cancer

Mother

Children

Sister

Other

Other Relatives

Other Cancer (please specify):

Social History

Do you use tobacco?

Yes No

Type

Packs per day

Quit(year)

Age started

Age stopped

Do you vape?

Yes No

# of years

Do you currently use recreational drugs?

Yes No

Type

Frequency

Do you consume alcoholic drinks?

Yes No

Type

Frequency/Amount

Do you have a history of alcoholism?

Yes No

Years of sobriety

Do you drink/consume caffeine?

Yes No

Type

Amount per day

Do you follow any special diets?

Yes No

Type

Allergies/Reactions

Please list any allergies or reactions to medications, foods, latex, or dyes, as well as the type of reaction you experienced (example: difficulty breathing, hives, etc.):

Medications/Dosages

Please list all medications and doses. Include vitamins, herbal supplements and over-the-counter medications:

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