* = Fields are required
Your GI Physician*
—Please choose an option—Frank Faris, MDAyaaz Ismail, MDDeb K. Mukhopadhyay, MDMickey Weise, MDTousif Pasha, MDHomer Iraninezhad, DOPick your GI Physician
Last Name*
First Name*
Middle Initial
Email*
Date of Birth*
Address*
Primary Insurance*
PLAN*
—Please choose an option—HMOPPO
Insurance ID #*
Secondary Insurance
Insurance ID #
Phone*
Referring physicians Name*
Date of Procedure*
Procedure*
Upper endoscopy (EDG)Lower endoscopy (colonoscopy)Both (upper and lower)SigmoidoscopyOther
Who will drive you home? and Phone number.
First Name and Phone
Check all that apply*
NonePenicillinSulfa drugsIodine ContrastCiproErythromycinOther
Other Allergy
NoneCoumadin (warfarin)PradaxaXareltoEliquisLisinoprilMetoprololBystolicBenicarMetforminJanuviaInsulin/Lantus etcSimvastatinCrestorVytorinAspirin 81mgAspirin 32mg
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
Check all that apply
Heart DiseaseHeart attack (MI)Atrial fibrillationAtrial fibrillationPacemakerAICD-defibrillatorCOPD/Emphysema/Lung diseaseStroke or TIAHypertensionDiabetesLow thyroid (hypothyroid)High cholesterolKidney DiseaseKidney dialysisParkinson's diseaseDifficulty with anesthesiaOn blood thinners other than aspirin
No major surgeriesCardiac pacemaker or AICDCoronary heart bypass surgeryHeart valve surgeryAbdominal aortic aneurysm surgeryColon surgeryGall bladder removedHiatal hernia repairedInguinal hernia repairedKnee or Hip replacement
Dentures?
I have denturesDo not have dentures
Implantable Devices(eg Pacemaker?)
Yes, I have implantsNo, do not have implants
Adverse reaction to anesthesia?
Yes, had problems with anesthesia.No, no problems with anesthesia.
Recent visit to hospital or emergency room?
Yes, visited ER/hospital recently.No recent visits to ER/hospital.
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