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. CANCELLATION AND DELINQUENT ACCOUNT POLICY 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
Employer:_____________________________________________________________________ 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:___________________________________________________________ Severity:_________________________________________________________________
(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:
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 Allergies
Other drugs_____________________ . No Yes
Food allergies____________________ No Yes
Endocrine Gastrointestinal - Lower Hematologic Musculoskeletal Cardiovascular Constitutional Symptoms Neurological Psychiatric Ears/Nose/Mouth/Throat Genitourinary Respiratory
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
Referred By: ___________________________________ Primary Care Physician: __________________________ Primary Care Physician Phone # ____________________
NEW PATIENT INTAKE FORM 
Have you ever had any of the following studies? (please check): 
Current Symptoms