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


2009 H1N1 Who is at greatest risk of infection z Wash your hands often with soap and water. If soap and water are not available, use an alcohol-based hand rub. 2009 H1N1 flu (sometimes cal ed “swine flu”) is a new with this new virus? z Avoid touching your eyes, nose and mouth. Germs influenza virus that is spreading worldwide among people. So far, younger people have been more


Vol. 73, 379–386, No. 3, February 15, 2002Copyright © 2002 by Lippincott Williams & Wilkins, Inc. POSTTRANSPLANT DIABETES MELLITUS IN KIDNEY ALLOGRAFT RECIPIENTS: INCIDENCE, RISK FACTORS, AND MANAGEMENT 1 M. ROY FIRST,2,7 DAVID A. GERBER,3 SUNDARAM HARIHARAN,4 DIXON B. KAUFMAN,5 AND University of Cincinnati Medical Center, Cincinnati, Ohio 45267; University of North Carolina at C

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