DEAN C. KRAMER, M.D.
1155 N.W. 64TH TERRACE
GAINESVILLE, FLORIDA 32605
TELEPHONE (352) 331-6736
PLEASE PRINT OUT THIS FORM.
BRING THE COMPLETED FORM TO THE OFFICE.
Please plan to arrive at least 15 minutes before your appointment time so that you may
register and have your office records prepared. Please bring all of your prescription
and non-prescription medications with you, including any nutritional supplements.
PATIENT INFORMATION (Please print or type)
Name:_____________________________________________________Sex: [ ] Male [ ] Female
Street address: __________________________________________DOB:_____________________
City:________________________________State:______________ Zip:_______________________
Social Security No.:_______________________ Driver's License No.:_____________________
Home phone:____________________________ Cell phone:____________________________
Present Employer:________________________ Office phone:___________________________
Employer’s Address:______________________ E-mail address:_________________________
Person to contact in case of emergency:________________________________________________
Address:________________________________ Phone No.:____________________________
Relationship:______________________________________________________________________
Person responsible for payment of your professional fees: [ ] myself
Other:___________________________________________________________________________
Address:_______________________________ Phone No.:____________________________
Relationship:______________________________________________________________________
Referred by:_______________________________________________________________________
INSURANCE INFORMATION
Is your illness covered by Workers’ Compensation insurance? [ ] YES [ ] NO
If you have insurance coverage, please indicate the type(s):
[ ] Medicare [ ] Medicare Number:_____________________________________
[ ] Blue Cross/Blue Shield [ ] Contract Number_____________________________
[ ] Other Insurance Coverage (list here)_____________________________________
_____________________________________________________________________
_____________________________________________________________________
*****AUTHORIZATION TO RELEASE INFORMATION AND ASSIGNMENT OF INSURANCE BENEFITS*****
I hereby authorize Dr. Kramer's medical practice to release to my insurance company(s) all
information that the company(s) may request concerning my illness or injury. I hereby assign
to Dr. Kramer's medical practice all monies to which I am entitled for the medical expenses
related to the services reported but not to exceed my indebtedness to Dr. Kramer's medical
practice. I understand that I am financially responsible to Dr. Kramer's medical practice for all
charges personally incurred here and agree to be personally and fully responsible for payment
of my account. I also authorize the exchange of my medical records and/or information
concerning my condition with other physicians, allied health providers, or medical facilities as
determined by Dr. Kramer and his medical staff to be in the best interest of my medical
treatment. A photocopy of this authorization shall be considered as effective and valid as the
original.
____________________________________ ____________________________________
Patient signature Date
PLEASE STATE YOUR REASON FOR SEEING DR. KRAMER
Describe your reason for seeing Dr. Kramer here:_____________________________
_____________________________________________________________________
MEDICAL HISTORY
Serious injuries: (describe the type of injury and approximate date of
occurrence)___________________________________________________________
Previous surgery: (place a "X" mark in the box next to the type of surgery you have
had and indicate the approximate date of the surgery)
[ ] Appendix_____________________ [ ] Hernia________________________
[ ] Cataracts_____________________ [ ] Hysterectomy__________________
[ ] Gallbladder___________________ [ ] Stomach ulcer surgery___________
[ ] Hemorrhoid surgery____________ [ ] Tonsils _______________________
[ ] Heart surgery _________________ [ ] Colon surgery_________________
Other surgery:_________________________________________________________
Have you ever had a colonoscopy? [ ] Yes [ ] No
Approximate date_______________________________________________________
PAST MEDICAL HISTORY
Please place an "X" mark in the box next to any illness or illnesses that you currently
have or have had in the past:
[ ] Crohn's Disease [ ] Heart murmur [ ] Rheumatic Fever
[ ] Ulcerative colitis [ ] High cholesterol [ ] Rheumatoid Arthritis
[ ] Uterine cancer [ ] High blood pressure [ ] Hemorrhoids
[ ] Esophageal reflux [ ] Irritable bowel syndrome [ ] Anemia
[ ] Stomach ulcer [ ] Chronic Constipation [ ] Asthma
[ ] Colon cancer [ ] Cirrhosis of the liver [ ] Blood Disorder
[ ] Breast cancer [ ] Hepatitis [ ] Blood Transfusion
[ ] Esophageal stricture (narrowing) [ ] Diverticulosis [ ] Diabetes
[ ] Helicobacter pylori infection [ ] Chronic Diarrhea [ ] Emphysema
[ ] Duodenal ulcer [ ] Gallstones [ ] Ovarian cancer
[ ] Colon polyp (s) [ ] Pancreatitis [ ] Radiation therapy
[ ] Esophageal varices [ ] Diverticulitis [ ] Thyroid disease
FAMILY HISTORY
Is your mother living? [ ] Yes [ ] No (cause of death)_______________________
Is your father living? [ ] Yes [ ] No (cause of death)_______________________
Please place an "X" mark in front of any of the following diseases or conditions that
have affected any member of your immediate family(mother, father, sister, brother, or
child):
[ ] Breast cancer [ ] Diabetes [ ] Ulcerative colitis
[ ] Colon cancer [ ] Heart attack before age 50 [ ] ____________________
[ ] Colon polyps [ ] Hypertension [ ] ____________________
[ ] Crohn's disease [ ] Ovarian cancer [ ] ____________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
ALCOHOL , TOBACCO, AND DRUGS
Do you drink alcohol? [ ] YES [ ] NO
If yes, how much alcohol do you drink per week?
_____cans of beer/week ____glasses of wine/week ____ounces of liquor/week
Do you use any tobacco products? [ ] YES [ ] NO
Do you use any recreational drugs? [ ] YES [ ] NO
ALLERGIES
List any drug allergies that you have:________________________________________
Place an "X" in the box, if you are allergic to any of the following:
[ ] Eggs [ ] Latex [ ] Penicillin [ ] Soy [ ] Sulfites [ ] Tape
What is your usual weight?________________ What was your approximate
weight one year ago? ________________ What is your present weight? __________
Have you gained or lost more than 10 pounds in the last 6 months? [ ] YES [ ] NO
REVIEW OF SYSTEMS (Place an "X" in front of all symptoms that apply)
General Cardiovascular Gastrointestinal (Continued)
[ ] Chills [ ] Chest pain on exertion [ ] Excess gas
[ ] Fatigue [ ] Palpitations [ ] Bloating and distention
[ ] Fever [ ] Awaken short of breath [ ] Heartburn or indigestion
[ ] Loss of appetite [ ] Swelling in feet or ankles [ ] Constipation
Skin Respiratory Urinary
[ ] Change is size of moles [ ] Cough [ ] Painful urination
[ ] Change in # of moles [ ] Breathless with exertion [ ] Frequent urination
[ ] Change in color of moles [ ] Coughing up blood [ ] Blood in urine
[ ] Skin rash [ ] Short of breath [ ] Urinary urgency
[ ] Wheezing [ ] Loss of urinary control
Ear, Nose, Throat
[ ] Hearing Loss Gastrointestinal Neurologic
[ ] Enlarged lymph nodes [ ] Difficulty swallowing [ ] Numbness
[ ] Neck mass [ ] Painful swallowing [ ] Seizures
[ ] Sore throat [ ] Nausea [ ] Fainting spells
[ ] Vertigo [ ] Vomiting [ ] Muscle weakness
[ ] Abdominal Pain
Eyes [ ] Vomiting blood Psychiatric
[ ] Painful or red eyes [ ] Passing blood in stool [ ] Loss of interest in life
[ ] Visual defects [ ] Diarrhea [ ] Feelings of hopeless
PLEASE LIST ALL YOUR PRESCRIPTION AND NON-PRESCRIPTION DRUGS
NAME OF DRUG Dose (mgm) NAME OF DRUG Dose (mgm)
1. 11.
2. 12.
3. 13.
4. 14.
5. 15.
6. 16.
7. 17.
8. 18.
9. 19.
10. 20.
WELCOME TO MY PRACTICE . . .
Appointments
Your first appointment with Dr. Kramer will consist of an interview, examination, and a discussion about your
diagnosis and treatment. You should allow at least an hour for this first appointment. Follow up
appointments will usually last 15 to 20 minutes.
Office visits are scheduled by appointment only. You should plan to arrive at least ten minutes early for your
scheduled appointment to allow the staff to update your records. Kindly notify the office staff if you
anticipate any delay in arrival. A late arrival may require that we reschedule your appointment.
Emergency Care
In the event of an emergency, you should call 911. If the issue is urgent and cannot wait until the next
business day, you should call your family physician or go to an immediate care center or a local hospital
emergency room.
Dr. Kramer does not provide emergency room care or inpatient hospitalization services. If you are
hospitalized, Dr. Kramer will work closely with your attending physician and arrange to provide any GI follow
up care in his office after you are discharged from the hospital.
Prescriptions and Renewals
All prescriptions and authorizations for renewals should be requested during office hours (8:00 a.m. to 4:30
p.m., Monday through Friday).
Telephone Calls
You are encouraged to call with any questions that you have about your medical care. These questions will be
answered either by Dr. Kramer or his staff during the scheduled time to return calls. You can be assured that
Dr. Kramer or one of his staff will respond as soon as possible.
Diagnostic Testing and Endoscopic Exams
If tests are required, Dr. Kramer’s staff will schedule your x-rays and laboratory studies. If an endoscopic
examination such as colonoscopy or upper endoscopy is recommended, Dr. Kramer’s staff will schedule your
examination with one of the endoscopy specialists either at the North Florida Endoscopy Center or the Shands
Endoscopy Center.
After any procedure, Dr. Kramer will receive a report and will contact you to discuss any findings. Dr. Kramer
will arrange for any necessary follow up GI care that you may need after your procedure.
Fees and Payments
Since each patient’s problems vary in complexity, it is difficult to provide in advance the exact fee for each
visit. As a general guideline, the fee for the initial office evaluation is approximately $250.
After each office visit, you will receive an itemized statement for that day’s services and the account balance
due. You will be asked to settle your account at that time.
DEAN C. KRAMER, M.D.
INTERNAL MEDICINE · GASTROENTEROLOGY
EDUCATIONAL BACKGROUND
Yale University (undergraduate)
Washington University (St. Louis) (Doctor of Jurisprudence-J.D.)
University of Missouri (Doctor of Medicine-M.D.)
Internship, General Internal Medicine, Shands Teaching Hospital, Gainesville, FL
Residency, General Internal Medicine, Shands Teaching Hospital, Gainesville, FL
Postgraduate Fellowship, Gastroenterology, Shands Teaching Hospital, Gainesville, FL
ACADEMIC APPOINTMENTS
Courtesy, Clinical Associate Professor of Internal Medicine, Shands Teaching Hospital,
Gainesville, FL
BOARD CERTIFICATION
Diplomate, American Board of Internal Medicine
Diplomate, American Board of Gastroenterology