Patient Interview Form Step 1 of 5 20% First Name(Required) Middle Initial Last Name(Required) Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Social Security # Date of Birth Sex Male Female Other Marital Status Single Married Separated Divorced Widowed Home Phone or Mobile Phone (Best)(Required)Work PhoneEmail(Required) Contact Preference No preference Email Letter/phone Decline to specify Other Patient Employer Insurance Name Policy ID # Policy Holder's Name Policy Holder's D.O.B. Spouse's InformationSpouse’s Name: Spouse’s Date of Birth Spouse’s SSN Spouse’s Employer Spouse’s Work #Spouse’s Mobile #Emergency ContactEmergency Contact (other than spouse) Relationship to Emergency Contact Emergency Contact Phone #Emergency Contact Mobile #Person(s), if any, we may discuss your medical/billing information withName Relationship Name Relationship Provider you are seeing today Referring Provider Reason for visit today Race Black/African American White Asian American Indian/Alaska Native Decline to specify Ethnicity Hispanic Not Hispanic or Latino Decline to specify Preferred Language English Spanish/Castilian Decline to specify *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? Yes No When did you have a colonoscopy? Where did you have a colonscopy? Have you ever had colon polyps? Yes No Have you ever had colon cancer? Yes No Has anyone in your immediate family ever had colon polyps? Yes No Which family member had colon polyps? Mother Father Sister Brother Daughter Son Has anyone in your immediate family ever had colon cancer? Yes No Which family member had colon cancer? Mother Father Sister Brother Daughter Son *All question in this box have been answered to to best of my knowledge. Review of Systems/Current Symptoms: Please check yes or noCardio chest pain difficulty breathing with exercise irregular heart beat palpitations peripheral edema Genitourinary dark urine frequent urination painful urination blood in urine urination during the night hesitancy Neurological frequent headaches numbness or tingling tremors Constitutional fatigue fever loss of appetite malaise sweats weight gain weight loss Hematologic/Lymphatic bleeding gums easy bruising prolonged bleeding palpable lymph nodes Psychiatric anxiety depression difficulty sleeping panic attacks ENMT dizziness nose bleeds sore throat hearing loss ringing in ears post nasal drip hoarseness halitosis (bad breath) Integumentary dryness itching jaundice rashes Respiratory cough difficulty breathing wheezing Musculoskeletal back pain muscle weakness stiffness Raynaud’s disease Allergies No known allergies No known drug allergies Penicillin Sulfa Codeine Cephalosporins Erythromycin Eggs Peanuts Latex Soy Other List other allergies Add RemovePharmacy Address Phone Consent to Import Medication HistoryDo you consent to having your medications obtained that have been purchased at your pharmacy? Yes No Do you currently take any medications? Yes No Current MedicationsNameDoseFrequency Add RemoveHave you had any immunizations? Yes No ListImmunizationDate Add Remove*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 ConditionsGastrointestinal Acid reflux Cirrhosis Colon polyp history Stomach ulcers Primary biliary cirrhosis Colon cancer Trouble swallowing Fatty liver Diverticulitis Gallstones Hepatitis A Diverticulosis Hiatal hernia Hepatitis B Irritable bowel disease Stomach cancer Hepatitis C Crohn’s disease Helicobacter pylori Abnormal liver tests Ulcerative colitis Barrett’s esophagus Pancreatitis Lactose intolerance Delayed gastric emptying Celiac disease Anemia Cardiovascular Atrial fibrillation Congestive heart failure Stroke Deep vein thrombosis Endocarditis Ischemic heart disease High blood pressure Transient Ischemic Attack (TIA) Difficulty breathing with exercise Mitral valve prolapse Coronary Artery Disease Carotid artery disease Heart Attack Other Cardiovascular Other Pulmonary/Other Asthma Arthritis Glaucoma C.O.P.D. Dementia Renal insufficiency Emphysema Chronic back pain Sickle Cell trait HIV Insulin dependent diabetes Seizures Cancer Cancer Type Diagnostic TestsGI Endoscopy Flexible Sigmoidoscopy EGD Capsule endoscopy Bravo ph study ERCP Esophageal dilation PEG tube placement Esophageal manometry Liver biopsy Other GI Endoscopy Other Radiology Tests (done in the past 6 months) Abdominal x-ray HIDA scan Abdominal ultrasound Sitzmarker colon transit study CT of the abdomen/Pelvis MRCP MRI of the abdomen/pelvis Small bowel series Gallbladder ultrasound Mammogram screening Previous Surgeries Gallbladder removed Whipple procedure (pancreatic cancer) Appendectomy Heart valve Reflux surgery Gastric bypass (Roux-en-Y) Bladder suspension Pacemaker Hiatal hernia repair Colectomy-partial C-section Cardiac stents Gastric lap band Total colectomy Prostate surgery Coronary artery bypass graft Small bowel resection Colostomy Hysterectomy Total hip replacement Exploratory laparotomy Hemorrhoidectomy Mastectomy Defibrillator Other Surgeries Add Remove Social HistoryOccupation Number of children Alcohol Use Yes No How much alcohol?TypeFrequency Add Remove*Please indicate the amount of frequency of each: Beer, Wine, LiquorTobacco Use Never smoked Former smoker Current every day smoker Current, some day smoker Light smoker Heavy smoker Smoker, current status unknown Type of SmokeTypeStartedQuitQuantityFrequency Add Remove*Please indicate the type of smoking: Cigarettes, Smokeless, OtherDrug Use Currently uses IV drugs Used IV drugs in the past Currently uses recreational drug(s) None Type of DrugsTypeQuantityFrequency Add Remove*Please indicate the type of drug use.Family Medical History: (This section pertains to your family, not your personal medical history)Crohn’s disease Yes No If yes, who in your family?RelationshipAge of diagnosis Add RemoveUlcerative colitis Yes No If yes, who in your family?RelationshipAge of diagnosis Add RemoveCeliac disease Yes No If yes, who in your family?RelationshipAge of diagnosis Add RemoveLiver disease Yes No If yes, who in your family?RelationshipAge of diagnosis Add RemoveMotherAliveDeceased/At age:Cause of deathFatherAliveDeceased/At age:Cause of deathSisterAliveDeceased/At age:Cause of deathBrotherAliveDeceased/At age:Cause of deathDaughterAliveDeceased/At age:Cause of deathSonAliveDeceased/At age:Cause of deathConsent to Share DataI consent to having my medical and demographic information shared with other health care entities. Yes No Reminder PreferenceI would like to receive preventive care and follow up care reminders. Yes No Reviewed with Patient Parent Guardian Not Present Authorization to Pay Benefits I hereby authorize payment of surgical and/or medical benefits directly to Gastroenterology Clinic, APMC (herein after GC), Endoscopy Center of Monroe, Inc. (herein after ECM) and/or West Monroe Endoscopy ASC, LLC (herein after WME) and further convey, transfer, and assign all of my rights in my insurance coverage to GC, ECM and/or WME for services rendered. I also hereby assign and transfer any and all rights, title, and interest to any claim for penalties and/or attorney fees arising under any state or federal law or regulation related to the payment of any claim for benefits to GC, ECM and/or WME. Regardless of the extent of the insurance coverage, I agree to be responsible for the entire balance. I also authorize release of information pertaining to my claim to my insurance company and/or companies or my attorney. Once the provider has obtained the patient's one-time authorization, the provider may submit any later claim on either an assigned or unassigned basis without obtaining any additional signature from the patient. In submitting claims, the provider should indicate "Patient request for payment on file." I hereby authorize GC, ECM, WME to furnish information to any requesting physician. Medicare Authorization I certify that the information given to me in applying for a payment under Title XVII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediary of carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf once the provider has obtained the patient's one time authorization. The provider may submit any later Medicare claim on either an assigned or unassigned basis without obtaining any additional signature from the patient. In submitting claims, the provider should indicate "Patient request for payment on file." I hereby authorize Gastroenterology Clinic, APMC, Endoscopy Center of Monroe, Inc. and/or West Monroe Endoscopy ASC, LLC to furnish information to any requesting physician.