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NRGI Detailed Patient Past Medical History.Xlsx

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NRGI Detailed Patient Past Medical History.Xlsx North Raleigh Gastroenterology, P.A. Patient Demographics Name: Today’s Date: First MI Last Social Security #: Date of Birth: Address: Street City State Zip Phone: ____ Alt Phone: Is it ok to leave a detailed message? Email:____________________________________________________ Preferred office? Employer: Work Phone #: Marital Status: Gender: Race: Ethnicity: In case of emergency, contact: Relationship and Phone #: Your primary care physician? _____________________Your pharmacy? ______________________________ Address Phone Your health insurance company:______________________________________________________________ Health insurance ID/Member/Subscriber number: ________________________________________________ Group number _____________________________________________________________________________ I agree to the NRGI patient portal terms of use. Initial I authorize NRGI to use email communication. Initial I authorize the release of any medical information necessary to provide care or to process claims and authorize payment to the physician for services rendered. I have read and agree to North Raleigh Gastroenterology's financial policy. I have received a copy of the Notice of Privacy Practices. Signature NRGI Patient History Questionnaire Name____________________________________Date of birth_____________Today's date _______________ Briefly describe your GI problems during the last 3 months. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Have you had any nausea? (Feeling like you are going to throw up) Yes No Have you vomited? (Actually thrown up) Yes No __________________________________________________________________________________________ Have you had heartburn? (Burning feeling in your chest or throat, also referred to as reflux) Yes No Have you had dysphagia? (Trouble swallowing or food getting stuck in esophagus) Yes No __________________________________________________________________________________________ Have you had any abdominal pain? Yes No a. If yes, please rate it on a scale of 1-10 ________ (1 is very mild, 10 is severe) b. Location of pain? Right Left Upper Lower (above belly button) (below belly button) Are you having any of the following gas symptoms? a. Belching Yes No b. Abdominal bloating (stomach is visibly distended at times) Yes No c. Flatulence (passing gas) Yes No __________________________________________________________________________________________ Are you having diarrhea? (Loose or watery bowel movements) Yes No Are you having constipation? (Infrequent bowel movements) Yes No How many bowel movements per day are you having? (If variable, give an average number per day) ________ per day Are you having any rectal bleeding? Yes No __________________________________________________________________________________________ Have you had any unexplained weight loss? Yes No a. If yes, please enter the number of pounds lost. ________ pounds Have you taken antibiotics recently? Yes No If yes, when __________________________________ what antibiotic? ____________________________ Have you traveled outside of the United States in the past year? Yes No If yes, when __________________________________ where?___________________________________ Is there any family history of a. Colon cancer? Yes No b. Inflammatory bowel disease (Crohn's or Ulcerative Colitis)? Yes No c. Celiac disease? Yes No 10/31/16 North Raleigh Gastroenterology, P.A. NRGI Patient Past Medical History Name _______________________________________ Date of birth _________________ Today's date _______________ Medication history ALLERGIES ___________________________________________________________ Are you allergic to: SOY EGGS PEANUTS LATEX NO allergies to these items Describe your reaction __________________________________________________________________________ List all medication including over the counter, vitamins, supplements, and herbals Name of drug Strength Frequency taken __________________________ ______________________ __________________________________________ __________________________ ______________________ __________________________________________ __________________________ ______________________ __________________________________________ __________________________ ______________________ __________________________________________ __________________________ ______________________ __________________________________________ Do you take blood thinners? YES NO Do you have a blood clotting disorder? YES NO Do you take any of the following? Aspirin Aleve BC/Goody's Powder Motrin Arthritis Meds Ibuprofen Coumadin Plavix Lovenox Xarelto Warfarin Effient Pradaxa Aggrenox Brilinta Eliquis None of these Medical history Height: __________ Weight: __________ Do you have or have you had any of the following? Cardiac: High blood pressure Pacemaker A Fib Heart valve replacement Irregular heart beat Stent Heart failure High cholesterol Angina Defibrilllator Heart attack NONE of these Pulmonary: Asthma COPD Emphysema Sleep apnea None of these GI: Acid reflux Barrett's esophagus Crohn's disease Ulcerative Colitis Colon polyps Celiac disease Diverticulitis Colon cancer Hepatitis Pancreatitis Ulcers Liver disease GU: BPH Urinary incontinence Abnormal menses Dialysis Kidney problems Urinary tract infections None of these Endocrine: Diabetes Thyroid None of these Neuromuscular: Stroke/TIA Parkinson's Migraines Seizures None of these Psychologic: Depression Anxiety Bipolar disorder Schizophrenia None of these North Raleigh Gastroenterology, P.A. NRGI Patient Past Medical History MISC: Anemia Lupus HIV/AIDS Rheumatoid disorder None of these Cancer: Colon Stomach Other:__________________________________ None Chemotherapy? YES NO Radiation? YES NO Other illnesses: ______________________________________________________________ None Are you currently pregnant? YES NO Are you currently breastfeeding? YES NO Family history Please indicate which family member has had any of the following: NONE Esophageal cancer ____________________ Stomach cancer _______________________ Colon cancer ________________________ Crohn's ______________________________ Liver disease ________________________ Ulcerative colitis_______________________ Pancreatic cancer ____________________ Celiac disease _________________________ Other _______________________________________________________________________________ Surgical/Endoscopy history Have you ever had a problem with anesthesia? YES NO If so, please describe _________________________________________________________ Have you had any of the following surgeries or procedures? If so, when? NONE Colon cancer screening Upper endoscopy Colonoscopy Cardiac surgery Heart stent Vascular surgery Gallbladder Appendectomy Hysterectomy Breast biopsy/surgery Colon surgery Valve replacement Obesity surgery Joint surgery Other surgical history ___________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ North Raleigh Gastroenterology, P.A. NRGI Patient Past Medical History Social history Occupation __________________________________________________________________ Marital status Single Married Divorced Widowed # of children ____________ Tobacco use Never Former Active _________ packs a day Alcohol use Never Former Active _________ drinks per week Illegal drug use Never Former Active Exercise None Light Moderate Heavy Please save your completed form and return to our practice by fax (844-587-9567) or email ([email protected]). **Important** Please check to see that your answers were saved before closing the document. For additional help, please see our troubleshooting guide. N North Raleigh Gastroenterology, P.A. Rajat Chander, M.D. R G Phone: (919) 846-9011 Fax: (844) 587-9567 I www.nrgi.org NRGI Financial Policy § Patients must pay their copay/co-insurance at the time of service. § You are responsible for making sure your primary care physician issues insurance-required referrals. § Our office will bill your insurance company for all services, but you remain responsible for ensuring payment. § When your insurance company responds, our office will bill you directly for your deductible, co- insurance, and services not covered by your policy. § You will be expected to pay in full for any services your insurance company deems related to a pre-existing condition. § We accept Visa, Mastercard, American Express, Discover, check or cash. § You are expected to pay your portion within 30 days of the bill date. § All past due accounts are charged a $10 fee and sent to an outside collections agent. § Patients are expected to notify our office immediately of insurance changes. § Please contact us (919-846-9011) and ask for our billing staff if you need an explanation of your bill. Policy for endoscopic procedures (colonoscopy and upper endoscopy) Dr. Rajat Chander will perform your procedure at either the Raleigh Endoscopy Center or WakeMed Cary Hospital. Your insurance company will be billed three fees. Dr. Chander’s office will bill a professional fee, Raleigh Endoscopy Center/WakeMed Cary Hospital will bill a facility fee, and Carolina Sedation Services will bill for anesthesia. If any tissue
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