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Toll Free: (800) 293-2634|Phone: (318) 325-2634|Fax: (318) 325-0717|

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Referring Providers CLICK HERE

Toll Free: (800) 293-2634|Phone: (318) 325-2634|Fax: (318) 325-0717|Email|

gastromds-logo@2x
Patient Portal
Pay My Bill
Appointments
Patient Forms

Referring Providers CLICK HERE

gastromds-logo@2x
Patient Portal
Pay My Bill
Appointments
Patient Forms
  • Providers
  • Medical Services
  • Preps
  • GI Diets
  • Patient Resources
  • Colon Cancer Screenings
  • Locations & Attending Hospitals
  • Endoscopy Centers
MAIN MENU
  • Providers
  • Medical Services
  • Preps
  • GI Diets
  • Patient Resources
  • Colon Cancer Screenings
  • Locations & Attending Hospitals
  • Endoscopy Centers
Toll Free: (800) 293-2634
Phone: (318) 325-2634
Fax: (318) 325-0717
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Patient Interview Form

Step 1 of 5

20%
Address
Sex
Marital Status
Contact Preference

Spouse's Information

Emergency Contact

Person(s), if any, we may discuss your medical/billing information with

Race
Ethnicity
Preferred Language

*Please answer the following questions as accurately as possible. Your past medical history and your family history are used to determine what your insurance will cover for procedures. Inaccurate information can affect how your claim is paid. Please initial in the box after answering the questions.
Have you ever had a colonoscopy?
Have you ever had colon polyps?
Have you ever had colon cancer?
Has anyone in your immediate family ever had colon polyps?
Which family member had colon polyps?
Has anyone in your immediate family ever had colon cancer?
Which family member had colon cancer?

Review of Systems/Current Symptoms: Please check yes or no

Cardio
Genitourinary
Neurological
Constitutional
Hematologic/Lymphatic
Psychiatric
ENMT
Integumentary
Respiratory
Musculoskeletal
Allergies
List other allergies
Pharmacy

Consent to Import Medication History

Do you consent to having your medications obtained that have been purchased at your pharmacy?
Do you currently take any medications?
Current Medications
Name
Dose
Frequency
 
Have you had any immunizations?
List
Immunization
Date
 
*Please list any of the following: Covid 19 vaccine, Flu vaccine, Hepatitis B vaccine, Hepatitis B Adult vaccine, Tetanus toxoid, Pneumonia.

Past or Present Medical Conditions

Gastrointestinal

Cardiovascular

Pulmonary/Other

Diagnostic Tests

GI Endoscopy

Radiology Tests (done in the past 6 months)

Previous Surgeries
Other Surgeries

Social History

Alcohol Use
How much alcohol?
Type
Frequency
 
*Please indicate the amount of frequency of each: Beer, Wine, Liquor

Tobacco Use
Type of Smoke
Type
Started
Quit
Quantity
Frequency
 
*Please indicate the type of smoking: Cigarettes, Smokeless, Other

Drug Use
Type of Drugs
Type
Quantity
Frequency
 
*Please indicate the type of drug use.

Family Medical History: (This section pertains to your family, not your personal medical history)

Crohn’s disease
If yes, who in your family?
Relationship
Age of diagnosis
 
Ulcerative colitis
If yes, who in your family?
Relationship
Age of diagnosis
 
Celiac disease
If yes, who in your family?
Relationship
Age of diagnosis
 
Liver disease
If yes, who in your family?
Relationship
Age of diagnosis
 

Mother
Alive
Deceased/At age:
Cause of death
Father
Alive
Deceased/At age:
Cause of death
Sister
Alive
Deceased/At age:
Cause of death
Brother
Alive
Deceased/At age:
Cause of death
Daughter
Alive
Deceased/At age:
Cause of death
Son
Alive
Deceased/At age:
Cause of death

Consent to Share Data

I consent to having my medical and demographic information shared with other health care entities.

Reminder Preference

I would like to receive preventive care and follow up care reminders.
Reviewed with
Authorization to Pay Benefits
Medicare Authorization

MONROE
Downtown Monroe
611 Grammont St.
Monroe, LA 71201

Phone: 318.325.2634
Fax: 318.325.0717

WEST MONROE
Glenwood Medical Mall
102 Thomas Rd., STE 114
West Monroe, LA 71291

Phone: 318.812.3303
Fax: 318.812.3304

RUSTON
Located inside the
Medical Plaza

411 E. Vaughn Ave., STE 202
Ruston, LA 71270

Phone: 318.232.7080
Fax: 318.325.0717

ENDOSCOPY CENTER
OF MONROE

Downtown Monroe
316 S. 6th St.
Monroe, LA 71201

Phone: 318.327.3107
Fax: 318.327.3110

ENDOSCOPY CENTER
OF WEST MONROE

Glenwood Medical Mall
102 Thomas Rd., STE 506
West Monroe, LA 71291

Phone: 318.388.6983
Fax: 318.388.8870

Patient Forms
Gastroenterologists Clinic logo
  • Providers
  • Medical Services
  • Preps
  • GI Diets
  • Patient Resources
  • Colon Cancer Screenings
  • Locations & Attending Hospitals
  • Endoscopy Centers
MAIN MENU
  • Providers
  • Medical Services
  • Preps
  • GI Diets
  • Patient Resources
  • Colon Cancer Screenings
  • Locations & Attending Hospitals
  • Endoscopy Centers

CONTACT US

Toll Free: (800) 293-2634
Phone: (318) 325-2634
Fax: (318) 325-0717

  • Providers
  • Medical Services
  • Preps
  • GI Diets
  • Colon Cancer Screenings
  • Patient Resources
  • Endoscopy Centers
  • Locations & Attending Hospitals
Gastroenterologists Clinic logo

CONTACT US

Toll Free: (800) 293-2634
Phone: (318) 325-2634
Fax: (318) 325-0717

  • Providers
  • Medical Services
  • Preps
  • GI Diets
  • Colon Cancer Screenings
  • Patient Resources
  • Endoscopy Centers
  • Locations & Attending Hospitals

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