Gastroenterology New Patient Registration Form

Patient Information

• Full Name: _________________ Date: _________________
• Date of Birth: ______________ Age: _____ Gender: _____
• Social Security #: _______________
• Address: _________________________________________
• Phone: (Home) ____________ (Cell) ____________
• Email: _________________________________________
• Emergency Contact: _____________ Phone: ____________
• Primary Care Physician: ________________________

Insurance Information

• Primary Insurance: _____________________________
• Policy #: _____________ Group #: _______________
• Secondary Insurance: ___________________________

Medical History

Gastrointestinal Symptoms (check all that apply)

• Abdominal Pain
• Acid Reflux/Heartburn
• Bloating
• Changes in Bowel Habits
• Difficulty Swallowing
• Nausea/Vomiting

Previous GI Procedures

• Last Colonoscopy Date: ________________________
• Last Upper Endoscopy Date: ____________________

Medical Conditions

• List current medical conditions: _________________
• Previous surgeries: ___________________________

Medications and Allergies

• Current medications (including OTC): ____________
• Drug allergies: _______________________________
• Food allergies: ______________________________

Family History

• Colon Cancer: [ ] Yes [ ] No Relation: _________
• Celiac Disease: [ ] Yes [ ] No Relation: _______
• IBD: [ ] Yes [ ] No Relation: ________________

Lifestyle

• Tobacco use: [ ] Never [ ] Current [ ] Former
• Alcohol use: [ ] Never [ ] Occasional [ ] Regular
• Caffeine intake: _____ cups/day

Authorization

I verify that the above information is accurate and complete:

Signature: _________________ Date: _____________