New patient intake form

Referred By: ___________________________________ Primary Care Physician: __________________________ Primary Care Physician Phone # ____________________ NEW PATIENT INTAKE FORM
(Please note that all information is strictly confidential)

Patient Name: _____________________________________DOB: _________Age: _____Gender_____
Social Security # __________-_________ -__________ Drivers License #:______________________ Marital Status: Single Married Address: ___________________________________________________________________________
Cell Phone #:___________________________ Home/Work Phone #___________________________
Pharmacy Name & Phone #:___________________________________________________________
Patient Email Address: ________________________________________________________________
Emergency Contact Name & Phone Number: _______________________________________________
Reason for Today’s Visit: _______________________________________________________________
Date of last general physical exam: _______________
Our goal at Chicago Gastro is to offer you comprehensive medical care. If you have insurance coverage, we will
make our best efforts to coordinate your care in a cost-effective manner within the limits of your insurance benefit. I
understand that I am financially responsible for all charges incurred for all treatment, including any co-payment,
deductible, or remaining balance amount after payment of possible insurance benefits. I authorize the release of
any medical information necessary to process any medical claims. I understand that if I have an HMO, it is my
responsibility to obtain all referrals for services rendered with our physicians.

In an effort to best serve the schedules of our patients: for office visits canceled less than 24 hours in advance, or
failure to keep an appointment, patients will incur a $50 charge. For procedures canceled less than 72 hours in
advance, or failure to keep a procedure appointment, patients will incur a $150 charge. All accounts not paid within
60 days will be forwarded to a Collections Agency and a 30% premium will be placed on all collections accounts.
I have read and understand the financial policy of this medical office and agree to be bound by its terms. I also
understand and agree that such terms maybe amended by the practice without prior written notice.

Signature of Patient or Legal Guardian
Printed Name Date
Primary Insurance Company Name: _____________________ Policy #:___________________
Insured Name: _________________ Insured SS#______________ Group #: _______________
Secondary Insurance Company Name: ___________________ Policy #: ___________________
May we discuss test results with a family member/friend? ________ Who? __________________
May we leave test results on your voicemail? _____________
History of Present Illness

Location of Discomfort:___________________________________________________________
(how severe is the discomfort on a scale of 1-10, where 10 is the worst pain) Duration: _______________________________________________________________ (how long have you had this problem – weeks, months, years) Modifying factors:_________________________________________________________ (what makes your symptoms better/worse)

Please Circle Any Gastrointestinal Medications you have taken within the past month:

Aspirin containing medications: Excedrin, Aspirin, Alka-Seltzer .
Arthritis medications: Nsaids, Motrin, Ibuprofen, Advil, Aleve .
Ulcer medications: Prilosec, Prevacid, Aciphex, Tagamet, Protonix, Nexium .
Stomach cramp medications: Librax, Levsin, Hyoscyamine, Bentyl NuLev, Zelnorm.
Nerve pills: Xanax, Valium, Prozac, Zoloft, Paxil .
Blood thinners: Coumadin, Aspirin, Heparin, etc. .
Anti nausea medications: Phenergan, Zofran, Compazine .
Laxatives: Correctol, Senokot, Lactulose, Miralax .
Herbal Products ______________________________ .
Gastric emptying pills: Reglan, Propulsid.
Fiber supplements: Metamucil, Fiber-Con, Citrucel, Konsyl .
Diet pills: Prescription or over-the-counter_________________________________ .
Cholesterol medications: Questran powder, Cholestid, Welchol .
Diarrhea medications: Imodium, Lomotil Pepto Bismol .
Colon medications: Asacol, Pentasa, Prednisone, Imuran, Purinethol, Methotrexate, Remicade

Medications: (Include over the counter and herbal products)
Name Dose /Frequency Condition Being Treated
________________________ ______________________ ____________________________
________________________ ______________________ ____________________________
________________________ ______________________ ____________________________
________________________ ______________________ ____________________________
________________________ ______________________ ____________________________
Allergies (medications, foods)
Medical History

Additional Medical Problems:
Arthritis/Gout ………………………… No Yes _________________________________________ Previous Hospitalizations/Surgeries/Serious
Seizures . No Yes Stress/Anxiety . No Yes
Social History

Alcohol Use: Never Rarely Moderate Daily
Tobacco Use: Never Previously, but quit Current packs/day_________
Caffeine Use: Never Rarely Moderate Daily
Drug Use: Never Rarely Moderate Daily Drugs used:_________________
Family Medical History
Please list any gastrointestinal problems in your family (parents, siblings, grandparents). Examples
include stomach/colon/liver problems; polyps, crohns, ulcerative colitis; breast/ovarian/colon/stomach/
liver cancer/ulcer disease
Have you ever had any of the following studies? (please check):

Barium enema Yes No ___________________ _______________________ __________ Colonoscopy Yes No ___________________ _______________________ __________ Upper GI Yes No ___________________ _______________________ __________ Ultrasound of gallbladder Yes No ___________________ _______________________ __________ CT of abdomen Yes No ___________________ _______________________ __________ Hida Scan Yes No ___________________ _______________________ __________ Gastric emptying scan Yes No ___________________ _______________________ __________ Yes No ___________________ _______________________ __________ Yes No ___________________ _______________________ __________ ERCP Yes No ___________________ _______________________ __________ Current Symptoms
Gastrointestinal - Upper
Other drugs_____________________ . No Yes Food allergies____________________ No Yes Endocrine
Gastrointestinal - Lower
Constitutional Symptoms


No job name

J. Med. Chem. 2004, 47, 5555-5566 Increased Anti-P-glycoprotein Activity of Baicalein by Alkylation on the A Ring Yashang Lee,†,| Hosup Yeo,†,‡,| Shwu-Huey Liu,§ Zaoli Jiang,§ Ruben M. Savizky,‡ David J. Austin,‡ andYung-chi Cheng*,† Department of Pharmacology, Yale University School of Medicine, Department of Chemistry, Yale University, andPhytoCeutica, Inc., New Haven, C

Microsoft word - farmacologia2.doc

A transmissão colinérgica no nervo frénico-diafragma do rato: modulação pré-sináptica. Alves, R., Moreira, R., Rocha, C. Departamento de Farmacologia, Faculdade de Farmácia da Universidade do Porto, Portugal, 2002 O objectivo do nosso trabalho foi o estudo da transmissão colinérgica no nervo frénico-diafragma. Para tal, foram utilizados diferentes fármacos (tubocurarina, decametón

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