1 Nurse Use Only: Height: Weight: Temp: BP: / Pulse: Flu: Pneumonia Mammogram Patient Health Information Patient Name: DOB: Today s Date: How did you hear about us/referring physician: Reason for Today s visit: Gastrointestinal Symptom Review Are you? Yes No Sometimes Experiencing unexplained weight loss Having fever or chills Having nausea Vomiting regularly Having heartburn symptoms Having difficulty swallowing Bothered by abdominal bloating or swelling Having abdominal pain or discomfort Constipated If yes, how many bowel movements per week Having diarrhea If yes, how many bowel movements per week If yes, do you have diarrhea at night Having any black, tarry stools Seeing red blood during bowel movement Having hemorrhoid symptoms Have you ever had ulcers Have you had an inflammatory disease of the small bowel or colon Have you had gallstones Have you had pancreatic problems Have you had hepatitis/other liver problems If yes, is your liver function currently normal Nurse Notes Doctor s Notes Have you had any recent tests? If so, When? By whom? Labs CT Colonoscopy MRI Ultrasound EGD ERCP X-Ray
2 Allergies: Reaction: Have you ever had any surgeries? When? Current Medication Dose: Quantity: If so, did you have any problems with the following? YES NO Pre procedure prep Procedure anesthesia During Procedure Post procedure complications If yes, please briefly describe the problem: Have you ever been diagnosed with any health problems? (i.e. high blood pressure, anemia) SOCIAL HISTORY Provide details regarding current and/or past use of the following: Alcohol (beer, wine, liquor) Yes No, If yes, how often? How many drinks? I.V. or Recreational Drugs Yes No, If yes, Usage? Tobacco (cigarettes, cigars, chewing tobacco) Yes No, If yes, How often? How many? Caffeine Yes No, If yes about how many cups per day?_ Smoking status Everyday Some Days Former Never Marital Status Single Married Divorced Widowed FAMILY HISTORY Colon Cancer Yes No Relation: Age at diagnosis Colon Polyps Yes No Relation: Age at diagnosis Celiac Disease Yes No Relation: Age at diagnosis Crohn s Disease Yes No Relation: Age at diagnosis Ulcerative Colitis Yes No Relation: Age at diagnosis Liver disease Yes No Relation: Age at diagnosis Other Cancer: Relation: Age at diagnosis Have you ever had any genetic testing to evaluate risk of Cancers? Yes No
3 Have you had any of the problems below in the past week? General: Fever Excessive Sweating Chills Fatigue Appetite change ENT: Sinus congestion Sore throat Headache Nose bleeds Hearing loss Mouth sores Trouble swallowing Dental problem Hoarseness Respiratory: Chest tightness Wheezing Shortness of breath Cough Cardiovascular: Chest pain Leg swelling Palpitations Genitourinary: Difficulty urinating Kidney stones Flank pain Blood in urine Urinary incontinence Dysuria (painful urination) Musculoskeletal: Joint pain Back pain Gait problems Joint swelling Muscle swelling Muscle weakness Skin: Color change Wound Rash Itching Neurologic: Dizziness Headaches Light-headedness Numbness Seizures Speech difficulty Fainting Weakness Confusion Hematologic: (Blood) Behavioral/ Psychological: Swollen lymph nodes Anemia Bleeds/bruises easily Agitation Behavior problem Self injury Decreased concentration Nervous/Anxious Difficulty sleeping
Acknowledgement of Review of Notice of Privacy Practices I understand the Health Insurance Portability and Accountability of 1996 (HIPAA), I have certain right to privacy regarding my protected health information. This information can and will be used to: Conduct, plan and direct treatment Obtain payment from third party payers Conduct normal healthcare operations such as quality assurance I have had the opportunity to read and understand the Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I also understand Houston Gastro Institute has the right to amend this notice and that I am entitled to an update copy of this notice if requested. I understand that I may request in writing that you restrict how my health information is used or disclosed to carry out treatment and healthcare operations. However, I understand that the facility may not accept these requested restrictions, but if accepted must abide by treatment. I understand that I have the right to review and copy my health information and request a change to any information that I believe is not complete list of each disclosure of my protected health information. Person Authorized to Receive Health Information: Patient Only Other: Name: Contact information: Ok to leave a message at home phone: Yes No, If yes, preferred phone #: Ok to email me: Yes No, If yes, Email address: I may revoke or terminate this authorization at anytime by submitting a written request to Houston Gastro Institute, pllc., Attn: Privacy Officer. Signature Date
Financial Policy Form All patients must read and sign this form prior to receiving services. It is your responsibility to provide us with your most current insurance information. If you fail to provide accurate insurance information in a timely manner, your insurance company may deny the claim. If the claim has been denied, you will be financially responsible for the services rendered. We must emphasize that, as medical providers, our relationship is with you, the patient, and not your insurance company. Your insurance is a contact between you, your insurance and possibly your employer. It is your responsibility to know and understand the level of services covered by your insurance company. We may accept assignment of insurance after verification of your coverage. Please be aware that some or perhaps all of these services provided may not be covered in full by your insurance company. It is your responsibility to provide us with your most current billing information. Payment in full due upon time of service., pllc will bill for the professional component of the fees (Physician Fee) for procedures performed outside of the office. Note that additional fees may apply under the following circumstances: i) Pathology Fees- if biopsies are taken ii) Anesthesia Fees- if general anesthesia is administered iii) Hospital or Surgery Center Facility Fees CANCELLATION POLICY In an effort to best serve our patients; for office visits we may charge a fee of $25.00 for the cancellation/failure to keep an appointment. Please make every effort to notify this office within 24-48 hours of your office visit or scheduled procedure if you must cancel or reschedule. 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 may be amended by the practice without prior or written notice. Signature Date
Address: Suite 206 Katy, Texas 77450 Fax: ( 832)-308-6581 Email: Website: IMPORTANT NOTICE ABOUT " NO SHOW" FEES We understand that there are sometimes circumstances that are beyond our control. We ask that you contact our office to let us know if you are unable to keep your scheduled appointment. We will happily cancel or reschedule your appointment for you. We make every effort to confirm your appointment well in advance. Please note that our office charges a "No Show Fee" if you fail to cancel or reschedule your appointment beforehand. I understand that there is a $25.00 fee for any "no show to scheduled appointments if appointment(s) is/are not cancelled or rescheduled at least 24 hours prior to the scheduled appointment. I understand that there is a $25.00 fee if I cancel or reschedule my scheduled appointment for an office visit three times or more consecutively. I understand that there is a $100.00 fee for any "no show to Endoscopy/colonoscopy procedure appointments if appointment(s) is/are not cancelled or rescheduled at least 48 hours prior to the scheduled appointment. I understand that there is a $100 fee if I cancel or reschedule my procedure twice or more consecutively. I understand that these no show fees are not covered by my insurance, and would be my responsibility to pay. Signature: Date:
AUTHORIZATION TO RELEASE HEALTH CARE INFORMATION Patient s Name: Date of Birth: I request and authorize the following practice: Name of Clinic: Phone Number: Fax Number: To release the medical records of the patient named above to: Dr. Vivian Asamoah, MD 777 S Fry Rd, Suite 206 Katy, TX 77450 This request and authorization applies to the release of: All Records Pathology Results Other: Note to office: Consult Notes Discharge Summary Labs Ultrasound Results ER Records Colonoscopy Report EGD Report CT Results MRI Results Pill Cam/ ERCP I understand that my express consent is required to release any health care information relating to testing, diagnosis, and/ or treatment for HIV (AIDS VIRUS), sexually transmitted diseases, psychiatric disorders/ mental health, or drugs and/or alcohol use, you are specifically authorized to release all health care information relating to such diagnosis, testing or treatment. Signature of Patient or Patient s Authorized Representative Date Relationship or status if signed by anyone other than the patient: P: 832-304-2004 F: 832-308-6581 777 S Fry Rd, Suite 206, Katy, TX 77450 www.houstongastroinstitute.com houstongastroinstitute@gmail.com