New Patient Form

Patient Information

Referring Physician:

Today’s Date:

Primary Care Physician

Primary Care Physician Phone:

Last Name:

First Name:

Middle Initial:

Date of Birth:

Race:

Ethnicity:

Preferred Language:

Marital Status:

Married Single Divorced Widowed Other

If other, specify:

Address:

City:

State:

Zip:

Home:

Cell:

Email address

Please check where we may leave a detailed message.

Home

Cell

Do not leave detailed message

Emergency Contact:

Relationship:

Phone:

PRIMARY INSURANCE

Insurance Name:

Insurance ID #:

Group or Plan #:

Network:

Policy Holder/Subscriber Name:

Relationship:

DOB:

Claims Address:

SECONDARY INSURANCE

Insurance Name:

Insurance ID #:

Group or Plan #:

Network:

Policy Holder/Subscriber Name:

Relationship:

DOB:

Claims Address:

RESPONSIBLE PARTY:

(Person responsible for payment)

Self

Spouse

Mother

Father

Other

Name:

DOB:

Address:

City:

State:

Zip:

I understand that I am personally responsible for all charges by my physician, whether or not paid for by insurance, and guarantee payment of the bill. I authorize payment of the medical benefits directly to the physician. I also authorize release of medical or other information to my insurance company.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient or Personal Representative

Date:

Health Questionnaire

Scott Browning

Jeffrey Manchio, MD

Richard Kalu, MD

No Preference

Legal Patient Name

Date of Birth

Preferred name if different

Reason for visit

MEDICATIONS: (Please list ALL medications that you are currently taking and their doses. Please include over the counter medications, vitamins, and supplements.

Add Medication

Are you allergic to any medications:

Yes No

If yes, please list the medication(s) and reaction(s) below

Preferred Local Pharmacy Name

Phone:

Address:

City:

State:

Zip:

PAST MEDICAL HISTORY: Please list any illnesses or medical problems you have had, and the approximate date

PAST SURGICAL HISTORY: Please list all surgeries you have had and the approximate date they occurred.

PREVIOUS COLON CANCER SCREENINGS: Please list the year of your most recent colon screening and the physician who performed the test.

Flexible Sigmoidoscopy

Colonoscopy

Other

Did you have polyps?

Yes No

FAMILY HISTORY:

Have any of your family had the following? Please list the relationship and AGE at the time of their diagnosis.

Colon or Rectal Cancer

Crohn’s Disease

Colon or Rectal Polyps

Ulcerative Colitis

SOCIAL HISTORY:

What is your marital status?

Single Married/Partner Widowed Other

Occupation?

Retired Unemployed Employed

Occupation:

Do you have children?

Yes No

If yes, how many?

Do you have any religious objection to blood transfusions?

Yes No

Would you like a chaperone during your visit?

Yes No

Which best describes your smoking status?

Never smoked

Current smoker

Former smoker

If current smoker, qty per day

If former smker, year quit

Do you use smokeless tobacco?

Yes No

If yes, type & qty:

Do you currently use any recreational drugs, including marijuana?

Yes No

If yes, type:

How often do you drink alcohol?

Never Daily Weekly Monthly Occasional

Drinks per week?

REVIEW OF SYMPTOMS: Please check all symptoms you currently have or have had in the past.

GENERAL

Recurrent fever

Significant weight change

Sweats

Anorexia

Fatigue

Malaise

Sleep disorder

EYES, EARS, NOSE & THROAT

Cataracts

Glaucoma

Eye pain

Tinnitus

Decreased hearing

Nasal congestion

Nosebleeds

Sore throat

Hoarseness

CARDIOVASCULAR

Abnormal heart valve

High blood pressure

Heart murmur

Heart attack

Peripheral edema

High cholesterol

Irregular heartbeat

RESPIRATORY

Wheezing

Asthma

Shortness of breath

Cough

Sleep apnea/CPAP

UROLOGIC/REPRODUCTIVE

Frequent urination

Difficulty urinating

Blood in urine

Urinary incontinence

Urinary hesitancy

Nocturnal urination

Prostate problems

Vaginal discharge

MUSCULOSKELETAL

Joint swelling

Joint pain

Arthritis

Shoulder pain/hand/wrist

Low back pain

Muscle weakness

Leg pain with exertion

DERMATOLOGIC

Rash

Itching

Hives

Skin cancer

Non-healing ulcers

PSYCHIATRIC

Depression

Anxiety

ENDOCRINE

Diabetes

Thyroid problems

Steroid use

HEMATOLOGIC

Bruising

Bleeding

Blood thinner use

ONCOLOGIC

Radiation

Chemotherapy

HEIGHT

WEIGHT

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