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GI Preferred
—Please choose an option—First AvailableTousif Pasha, MDMickey Weisz, MDAyaaz Ismail, MDJaclyn Crame, PASelect your physician
Referring Provider*
Last Name*
First Name*
Middle Initial
Date of Birth*
Mobile Phone
Email*
Home Address*
Race*
—Please choose an option—American Indian/Native AlaskanAsianBlack/African AmericanNative Hawaiian/Pacific IslanderWhiteHispanic/LatinoOther
Preferred Language
Emergency Contact
First name - last name and relationship
Emergency Phone
Emergency contact phone
Primary Insurance
PLAN
—Please choose an option—HMOPPO
Insurance ID #
Secondary Insurance
Phone
Pharmacy Name
Pharmacy - Major Cross Streets - Zip Code
Pharmacy Phone
Reason for Visit
Screening for colon cancerHistory of colon polyps/cancerFamily history of polyps/cancerAbdominal PainChest painDiarrheaConstipationChange in bowel habitsHeartburnDifficulty swallowingNauseaVomitingPoor appetiteRectal BleedBlood in stoolWeight lossAnemiaHepatitis CAbnormal liver testOther
Check all that apply*
NonePenicillinSulfa drugsIodine ContrastCiproErythromycinOther
Other Allergies
Please type allergic reactions and other medication allergies?
NoneBlood thinners (Coumadin (warfarin), Pradaxa, Xarelto, Eliquis)LisinoprilAmlodipineMetoprololBystolicBenicarMetforminGlipizideInsulin (e.g lantus)Levothyroxine (e.g. synthroid)Statins (Simvastatin, Crestor, Vytorin)Aspirin 81mg , Aspirin 325mg
Other Medications
Please type names of other medications you take
Smoking
—Please choose an option—Never smokedEx-smokerCurrent smokerSmoking history
Alcohol
—Please choose an option—Social useModerate useHeavy useQuit, heavy use in pastQuit, moderate use in pastQuit, moderate use in pastDo not drinkAlcohol history
Flu Vaccination
—Please choose an option—YesNoDid you get the Flu Vaccination?
Height
Height Ft' Inches" (5'9")
Weight
(lbs)
Check all that apply
Heart Disease, Heart attack (MI), Atrial fibrillationPacemaker, AICD-defibrillatorHeart failureHypertensionDiabetesCOPD/Emphysema/Asthma/Lung diseaseLow Thyroid (hypothyroidism)High cholesterolAnxietyDepressionBipolarChronic kidney diseaseKidney DialysisStroke or TIAParkinson's diseaseSeizure disorderDifficulty with anesthesiaEndocarditis (heart valve infection)Sleep apneaMigraine headachesGall stonesPancreatitisPeptic ulcer disease (bleeding)
No major surgeriesCardiac pacemaker or AICDCoronary heart bypass surgeryHeart valve surgeryAbdominal aortic aneurysm surgeryGastric bypassGastric sleeveGastric lapbandGall bladder removedHiatal hernia repairInguinal hernia repairKnee or Hip replacementSplenectomyBladder repair
Family History (Parents, siblings, children)*
Colon cancerUterine cancerLiver cancerStomach cancerEsophageal cancerBarrett's esophagusCrohn's or Ulcerative ColitisCeliac diseaseNo family history (above)
FeversHeadache or Blurred visionSore throat, hoarsenessCoughWheezingBloody sputumShortness of breathChest painPalpitationsSwelling of legsMuscle ache or Joint pain or joint swellingDifficulty urinatingSkin rash or ItchingBleeding tendency or Easy bruisingWeight loss or loss of appetiteDepressed or sadAnxious or nervous
I acknowledge that this form may not be secure. Any health information I choose to share on this form is at my own risk.
Please bring pertinent records, medication, supporting laboratory, and radiology studies with you. Please note that some insurances require prior authorization- Please contact your primary provider to obtain and confirm you have the appropriate authorization. Without authorization you may not be able to see the physician. Thank you for understanding. We will contact you within 24-48 hrs to schedule an appointment.
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