Established Patient Appointment Form

—Please choose an option—First AvailableTousif Pasha, MDMickey Weisz, MDAyaaz Ismail, MDSelect your physician

—Please choose an option—HMOPPO

—Please choose an option—PPO (No prior authorization required)HCP (HMO) WILL NEED prior authorization from Primary Provider BEFORE confirming appointmentHPN (HMO) WILL NEED prior authorization from Primary Provider BEFORE confirming appointmentHPN Medicade (HMO)- WILL NEED prior authorization from Primary Provider BEFORE confirming appointment

Pharmacy - Major Cross Streets - Zip Code

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

Briefly describe reason for appointment

NonePenicillinSulfa drugsIodine ContrastCiproErythromycinOther

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

Please type names of other medications you take

—Please choose an option—Never smokedEx-smokerCurrent smokerSmoking history

—Please choose an option—Social useModerate useHeavy useQuit, heavy use in pastQuit, moderate use in pastQuit, moderate use in pastDo not drinkAlcohol history

—Please choose an option—YesNoDid you get the Flu Vaccination?

Height Ft' Inches" (5'9")

(lbs)

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

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