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					R. KIRK ELLIOTT, D.O.

CLINICAL GASTROENTEROLOGY, INC.  EDWARD T. SCHIRACK, D.O. 

MONA SHAY, D.O.

PATIENT INFORMATION
Date: _________________ Primary Care Doctor: ______________________ Referring Doctor: _________________________ Patient:

___________________________________________________________________________________ __________________________________________________________________________________

Address: City:

________________________________ State: ________________ Zip Code: ________________________ _______________________

Home Phone No._________________ Cell No._____________________ E-mail Address:

Social Security No. ________________________________________ Date of Birth: ______________________________________ Marital Status: (please circle): Married Widowed Divorced Single Sex (please circle): Male Female

Employer: _________________________________________________City: ____________________________________________ Work Phone No. ____________________________ Occupation: ___________________________________________________ Your Employment Status: (please circle) Active Retired Disabled Unemployed

Emergency Contact (Not currently living with you): _______________________________________ Phone: ____________________ Relationship to Patient: _______________________________________________________________________________________ Spouse’s Name: _____________________________________________________________________________________________ Spouse’s Social Security No. ____________________________________ Date of Birth: __________________________________ Spouse’s Employer: __________________________________________________________________________________________ Employer’s Address: _________________________________________________________________________________________ Work Phone No. ______________________________Occupation: ___________________________________________________ Spouse’s Employment Status: (please circle)

Active

Retired

Disabled

Unemployed

Pharmacy Name: ____________________________

Pharmacy Phone: _______________________

PRIMARY INSURANCE: __________________________________________________________________
Contract/I.D. No. ________________________________________ Group No./Name: ___________________ Policyholder Name: ______________________________________ Relationship: _______________________ Pre-authorization Phone No. _____________________________

SECONDARY INSURANCE: _______________________________________________________________
Contract/I.D. No. _______________________________________ Group No./Name: ____________________ Policyholder Name: _____________________________________ Relationship: ________________________ Pre-authorization Phone No. ___________________________

R. KIRK ELLIOTT, D.O.

CLINICAL GASTROENTEROLOGY, INC.  EDWARD T. SCHIRACK, D.O. 

MONA SHAY, D.O.

Patient Name: _________________________________________

Date: ________________

Reason for Today’s Visit: _______________________________________________________ MEDICAL HISTORY: Atrial fibrillation Alzheimer disease Anxiety Angina Anemia Asthma Barrett’s Esophagus Coronary Artery Disease Cancer Location: Cirrhosis Colon polyps Colon cancer COPD/emphysema Crohns disease Depression Deep vein thrombosis-clot SURGICAL HISTORY:
YEAR

(Please check the box next to any condition you had or have)
Diverticulosis Diverticulitis Non-Insulin Diabetes Insulin Diabetes Endometriosis Fibromyalgia Gallstones H. pylori HIV High cholesterol High Blood Pressure Hyperthyroidism Hypothyroidism Irritable bowel syndrome Osteoarthritis Osteoporosis
YEAR

Pancreatitis Pulmonary embolism Peptic stricture Stroke Peptic ulcer Renal failure Rheumatoid arthritis Rheumatic fever Seizure Sleep apnea Ulcerative Colitis Other diseases:

(Please check the box next to any surgery you had including year)
YEAR

Abdominal aortic aneurysm Appendix Bladder suspension Bowel obstruction Breast biopsy Breast removal Carotid artery Carpal tunnel Heart Valve Replacement Colon resection Open Heart Surgery Diverticulosis resection

Gallbladder, laparoscopic Gallbladder, open Heart catheterization with balloon angioplasty with stent placement Heart pacemaker with defibrillator Hiatal hernia repair Inguinal hernia repair Hip replacement Knee replacement Hemorrhoidectomy

Hysterectomy Removal of ovaries Tubal ligation Peptic ulcer surgery Prostate surgery Prostate radiation seeds Skin cancer removal Tonsillectomy Liver biopsy Lung resection Other:

Please check all of the following GI Symptoms that apply to you; Abdominal pain Diarrhea Trouble Swallowing Constipation Heartburn Rectal Bleeding Nausea Black Tarry Stools Vomiting Weight Loss Change in Bowel Habits Other: Have you ever had a colonoscopy test? (please circle) Yes No If yes, what year? __________

R. KIRK ELLIOTT, D.O.

CLINICAL GASTROENTEROLOGY, INC.  EDWARD T. SCHIRACK, D.O. 

MONA SHAY, D.O.

Patient Name: ________________________________________ DRUG ALLERGIES: YES NO LATEX ALLGERY: YES NO

PLEASE LIST ALLERGIES BELOW:

MEDICATIONS:

(Please list your medications and dosages that you currently are taking)