1. Please print, complete and sign these forms. 2. Bring completed
Pierre Castera, MD Ben Mizrahi, MD Lina O’ Brien, MD Jeremy Cravens, MD Phone (816)941-0800 Fax (816)941-0080 St. Joseph Health Center Location 1004 Carondelet, Suite 430 Kansas City, MO 64114 BULIDING B-Medical Mall Overland Park Location 10100 W 87th St. Suite 200 Overland Park, KS 66212 MARK I Building Northland Location 6060 North Oak Trafficway Suite 101 Gladstone, MO 64118 PARK IN BACK OF BUILDING 1. Please print, complete and sign these forms. 2. Bring completed paperwork with you to your appointment. 3. Bring your insurance card(s). 4. Bring a photo I.D. 5. If you have FMLA or any other form that needs to be completed, it must be given to the front desk. The $20 fee to complete each form must be paid at the time you request to have the form completed. 6. Arrive 15 minutes before your scheduled appointment time for us to be able to process your paperwork before your appointment time. Thank you and we look forward to meeting you! COLORECTAL SURGERY ASSOCIATES, P.C. Patient Name: ___________________________________________Today’s Date: _________ Home address: Street: ____________________________________________ City: _____________________ State: _______ Zip: ______ Phone: ________________ Cell Phone: _________________ Work Phone: ________________ Referring Physician: __________________ Primary care physician: _____________________ Birth Date: ______________________ Age: _______ Sex: Male Female Transgender Marital Status: (please circle) Single Married Partnership Divorced Widowed Social Sec #: ______________ Race: (please circle) American Indian Alaska Native Asian Native Hawaiian Black African American Hispanic White Other Race Other Pacific Islander Unreported/refused to Report Employment Status: ______________ Employer: _______________________________ Pharmacy of Preference:____________________ Pharmacy Address:________________________________ Emergency Contact: ________________________Relationship: ________________________ Home Phone: _____________________________ Alternative Phone: _________________________ *FOR YOUR PRIVACY PLEASE NOTE THAT WE MAY CONTACT THIS PERSON IF WE CAN NOT CONTACT YOU* Responsible Party (if other than patient/ minor): ______________________________________ Phone: ________________ Address (if different): ____________________________________ Primary Insurance Name: ____________________________________ Policy #: _____________________________ Group #: ________________________________ Subscriber name: ______________________DOB: _______________SS#: ________________ Secondary Insurance Name: __________________________________ Policy #: _____________________________ Group #: _______________________________ Subscriber name: ______________________DOB: _______________SS#: ________________ HIPAA Consent to View HISTORY OF SCRIPTS. Signed by patient or authorized person. I, the undersigned, give consent to Colorectal Surgery Associates to view my prescription history (please date and sign) Signature:________________________________ Date:_______________ I certify that I have insurance coverage with the company (ies) listed in the previous section of this form. I assign directly to Colorectal Surgery Associates all insurance benefits, if any, otherwise payable to me for services rendered. I authorize the use of my signature on all insurance submissions and claims. I understand that I am financially responsible for all charges whether or not paid by insurance. The above named doctors may use my health care information and may disclose such information to my insurance company (ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. To insure the continuity of care, I also authorize Colorectal Surgery Associates to provide the information regarding my treatment and any medication I received at this office to my primary care physician. Your first statement for a new balance due will be mailed to you free of charge. However, there will be a $5 statement charge for each statement thereafter for all old balances. Signature: _________________________________ Date: _________________ (Patient or Parent/Legal guardian) Medicare Patients Please Sign I request that payment of authorized Medicare benefits be made on my behalf to Colorectal Surgery Associates for any services furnished to me by their physicians or nurse practitioner. I authorize any holder of medical information about me to release to CMS(Center of Medicare&Medicaid) and its agents any information needed to determine these benefits or the benefits payable for the related services. Signature:_________________________________ Date: _________________ HIPAA NOTICES OF PRIVACY PRACTICES Colorectal Surgery Associates is required by law to maintain the privacy of your health information and provide you notice of our legal duties and privacy practices with respect to your health information. A copy of Colorectal Surgery Associates Privacy Practices is available to you at CSAKC.com website or you can ask for a copy to be provided to you during your visit. I have reviewed Colorectal Surgery Associates’ notice of privacy practices on their website or have been provided a copy during my visit. Printed Patients name: _________________________Date of Birth: ____________________ Signature: __________________________________________ Date: ________________ (Patient or Patient representative) Permission to Disclose Information In order to protect your confidentiality and to comply with government regulation(HIPAA), Colorectal Surgery Associates is required to obtain authorization from you in order to release messages and/or provide information regarding your care with any person(s) other than yourself. RELEASE OF MEDICAL/APPOINTMENT INFORMATION: The physicians or staff at Colorectal Surgery Associates may discuss my medical information and/or care with the following: Please Check All That Apply Spouse Name: ___________________________ Name: Relationship: ___________________________ Phone:__________ Name: Relationship: ____________________________ Phone:__________ Name: Relationship: ____________________________ Phone:__________ MESSAGES: I give my consent to the physicians and staff of Colorectal Surgery Associates to leave or discuss treatment, surgery, labs, radiology results or other information regarding my care as follows. Please Check All That Apply On answering machine or voicemail at home On cell phone On answering machine or voicemail at work E-Mail for Patient Portal: EMAIL ADDRESS:_________________________________ I do not consent to messages being left at home, work or with any other person Pts Name:______________________ Age:_____ D.O.B /____ Social History: Caffeine Use O Yes O No If Yes, Number of cups a Day?_____ Marital Status: O Single O Married O Divorced O Widowed O Partnership Occupation:__________________________ Medical History: High Blood Pressure O Yes O No Low Blood Pressure O Yes O No COPD O Yes O No Heart Disease O Yes O No Sore and/or Bleeding Gums O Yes O No Missing Teeth O Yes O No Dentures/Crowns/Bridges O Yes O No Dental Fillings O Yes O No Bright Red Stools O Yes O No Anal Burning and Itching O Yes O No Anal Pain O Yes O No Bleeding on Toilet Tissue O Yes O No Urge to Defecate O Yes O No Frequent Stools O Yes O No Stool Leakage O Yes O No Black Stools O Yes O No Laxatives O Yes O No If Yes, Which One?_____________________ Pain After Eating O Yes O No If Yes, Where?_________________________ Irritable Bowel Syndrome O Yes O No Ulcerative Colitis O Yes O No Crohn’s Disease O Yes O No Cancer O Yes O No If Yes, Type(s):_________________________ Arthritis (including Rheumatoid) O Yes O No Lupus O Yes O No Fibromyalgia O Yes O No Kidney Disease O Yes O No Dialysis O Yes O No Jaundice O Yes O No Hepatitis O Yes O No If Yes, Type:___________________ Diabetes O Yes O No If Yes, Type:___________________ Anemia O Yes O No HIV O Yes O No Pneumonia O Yes O No Epilepsy O Yes O No Seizure Disorder O Yes O No Thyroid Disease O Yes O No Anesthesia Problems O Yes O No Birth Defect O Yes O No / / Today’s Date / /__ Blood Clots O Yes O No Sleep Apnea O Yes O No Stomach Ulcers O Yes O No TB(Tuberculosis) O Yes O No Surgical History Colonoscopy O Yes O No If yes,Yr?______________________ By Whom_______________________ Polyps Found O Yes O No Normal Results O Yes O No Laparoscopy O Yes Ono Yr?________ Colon resection O Yes O No Yr?________ Pacemaker O Yes O No Yr?________ Low Anterior Resection O Yes O No Yr?________ Artificial joint(knee, hip, etc) O Yes O No Yr?________ Heart Bypass O Yes O No Yr?________ Thyroid O Yes O No Yr?________ Prostate O Yes O No Yr?________ Mastectomy O Yes O No Yr?________ If Yes, O Laparoscopic O Open Hysterectomy O Yes O No Yr?________ If Yes, O abdominal O vaginal Gallbladder O Yes O No Yr?________ If Yes, O Laparoscopic O Open Appendectomy O Yes O No Yr?________ If Yes, O Laparoscopic O Open Heart Stent(s) O Yes O No Yr?________ Breast lump O Yes O No Yr?________ Heart Valve O Yes O No Yr?________ Bladder/cystocele/rectocele) O Yes O No Yr?________ Hernia O Yes O No Yr?________ Tonsillectomy O Yes O No Yr?________ Blood Transfusion O Yes O No Yr?________ Nissen Fundoplication or Stomach Stapling O Yes O No Yr?________ List any other surgeries/hospitalization below: _______________________________________ _______________________________________ _______________________________________ Women Only Menstrual History: Last Menstrual Period:______________ Are You Pregnant: O Yes O No Obstetrics: _____# Pregnancies _______#Vaginal ________# C-Sections History or Episiotomy or Vaginal Tearing O Yes O No Review of Systems: PLEASE CIRLCE ALL THAT YOU ARE EXPERIENCE AT THIS TIME Weight Loss Loss of Appetite Fever Weakness Bleeding Problem Fatigue Night Sweats _______________________________________________________________________________________________________ Cold Cough Nose Bleeding Hearing Loss Change in Voice Sore Throat Sinus Pain ________________________________________________________________________________________________________ Shortness of Breath Dizziness Murmurs Chest Pain Palpitations Edema Blue Coloration of Skin Varicose Veins ________________________________________________________________________________________________________ Difficulty Swallowing Diarrhea Abdominal Pain Nausea Blood in Stool Vomiting Constipation Change in Bowel Habits Heart Burn ________________________________________________________________________________________________________ Joint Swelling Joint Pain Leg Cramps Joint Stiffness Sciatica Fractures Carpel Tunnel ________________________________________________________________________________________________________ Depression Sleep Disturbances Suicidal Ideation ADHD Mental/ Physical Abuse Anxiety ________________________________________________________________________________________________________ Rash Moles Eczema Hive Keloid Formations Skin Cancer Bruising ________________________________________________________________________________________________________ Excessive Sweating Cold Intolerance Excessive Thirst Excessive Urination Sleep Disturbance Heat Intolerance ________________________________________________________________________________________________________ Headaches Tingling Numbness Memory Loss Dizziness Seizures Insomnia Gait Abnormality ________________________________________________________________________________________________________ Eye Irritation Drainage from Eyes Blurring of Vision Loss of Vision ________________________________________________________________________________________________________ Easy Bleeding Swollen Glands Loss of Appetite ________________________________________________________________________________________________________ FEMALE ONLY—Two Lines Below Heavy Periods Menstrual Cramps Difficulty Urinating Hot Flashes Vaginal Discharge Increased Urinary Frequency Pelvic Pain MALE ONLY—Two Lines Below Increased Urination Frequency Difficulty Urinating Hernia Undescending Testicle Kidney Disease Hard Testicle Retractile Testicle ____________________________________________________________________________________________________________________ Social History--SMOKING, ALCOHOL AND DRUG QUESTIONAIRE: (Please Fill in Bubbles)—TO BE COMPLETED BY ALL PATIENTS Smoking Screening Are you a: O current smoker O former smoker O nonsmoker If you are a current smoker: Are you a: O light tobacco user O heavy tobacco user If "former smoker": How long has it been since you last smoked? O <1 month O 1-3 months O 3-6 months O 6-12 months O 1-5 years O 5-10 years O >10 years If "current smoker": Are you interested in quitting? O Ready to quit O Thinking of quitting O Not ready to quit If "current smoker": How many cigarettes a day do you smoke? O 5 or less O 6-10 O 11-20 O 21-30 O 31 or more If "current smoker": How soon after you wake up do you smoke your first cigarette? O within 5 minutes O 6-30 minutes O 31-60 minutes O after 60 minutes If "current smoker": How often do you smoke cigarettes? O every day O some days O but not every day Alcohol Screening Did you have a drink containing alcohol in the past year? O Yes O No If Yes: How many drinks did you have on a typical day when you were drinking in the past year? O 1 or 2 drinks O 3 or 4 drinks O 5 or 6 drinks O 7 to 9 drinks O 10 or more If Yes: How often did you have a drink containing alcohol in the past year? O Never O Monthly or less O 2 to 4 times a month O 2 to 3 times a week O 4 or more times a week Drug Screening Have you used drugs other than those for medical reasons in the past 12 months? O Yes O No Pts Name:______________________________ Age:_____ D.O.B / / Today’s Date / /___ Family History-Please check all that apply to your family medical history. Please indicate Maternal (M) or Paternal (P) relationship in space provided for Grandmother, Grandfather, Uncle and Aunt. Colon Cancer Colon polyps Rectal or Anal Cancer Gastric cancer Pancreatic cancer Breast Cancer Ovarian Cancer Mother Mother Mother Mother Mother Mother Mother Uterine/Endometrial Cancer Mother Ulcerative colitis Mother Liver disease Mother Diabetes Mother Coronary artery disease Mother Crohn’s Disease Mother Father Father Father Father Father Father Sister Sister Father Father Father Father Father Brother Sister Grandmother ____ Brother Sister Grandmother ____ Brother Sister Grandmother ____ Brother Sister Grandmother ____ Brother Sister Grandmother ____ Brother Sister Grandmother ____ Grandmother____ Aunt____ Grandmother____ Aunt____ Brother Sister Grandmother ____ Brother Sister Grandmother ____ Brother Sister Grandmother ____ Brother Sister Grandmother ____ Brother Sister Grandmother ____ Grandfather____ Grandfather____ Grandfather____ Grandfather____ Grandfather____ Grandfather____ Uncle____ Uncle____ Uncle____ Uncle____ Uncle____ Uncle____ Aunt____ Aunt____ Aunt____ Aunt____ Aunt____ Aunt____ Grandfather____ Grandfather____ Grandfather____ Grandfather____ Grandfather____ Uncle____ Uncle____ Uncle____ Uncle____ Uncle____ Aunt____ Aunt____ Aunt____ Aunt____ Aunt____ Medications: List all medications you presently take. Also please list any blood thinning medications (aspirin, Plavix, Coumadin, fish oil, Vitamin E, cardiotabs) NAME OF MEDICATION Allergies: Drug/Agent Patient Signature:______________________________ Date:________________________________________ REASON DOSAGE Reaction
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