Advanced Gastroenterology Associates L.L.C Homayoon Mahjoob, MD, M.S.P.H [email protected] Contact: (301) 352- 7771 Fax: (800) 681-5070 Website: www.AdvancedGiWorld.com REGISTRATION FORM Primary Care Physician: Today’s date: PATIENT INFORMATION Patient’s Last Name: First: Middle: Marital Status (circle one) Single / Mar / Div / Sep Is this your legal name? If not, what is your legal name?  Yes  No Street Address: Birth date: / City: Social Security #: Occupation: (Former name): Home #: Employer: Sex: M Zip code: / State: Cell# F Email Address: Employer Address:  Physician, Name:_________________ Referred by: Age: Employer Phone Number:  Hospital Phone:_________________  Insurance Plan  Family  Internet/Directory  Friend  Other: INSURANCE INFORMATION (Please give your insurance card to the receptionist.) Person responsible for bill: Birth date: Address (if different): / /   No Yes Is this person a patient here? Occupation: Employer: Home phone no.: ( ) Employer address: Employer phone no.: ( Is this patient covered by insurance? Subscriber’s name: Please indicate primary insurance:  Yes  No Subscriber’s SSN Birth date: / Patient’s relationship to subscriber: Name of secondary insurance (if applicable): Patient’s relationship to subscriber:  Self  Spouse Group no.:  Spouse Policy no.: /  Child  Child Copayment: $  Other Subscriber’s name:  Self ) Group no.: Policy no.:  Other IN CASE OF EMERGENCY Name of local friend or relative (not living at same Relationship to address): patient: Home phone#: Work phone#: The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Advanced GI Associates LLC or insurance company to release any information required to process my claims. Please note you will receive only one statement for any patient balance due. If not paid within 30 days, the account will be considered for collections and associated fees unless arrangements have been made with our office. Patient/Guardian signature Date MEDICAL HISTORY Name:_______________________ Date: ________ Age:___________ Referring Physician: ________________________________ Main Concern for Visit: ________________________________ DOB: __________ PAST MEDICAL HISTORY HAVE YOU BEEN DIAGNOSED YES NO IF YES, PLEASE EXPLAIN DISEASE AND TIME OF DIAGNOSIS WITH ANY OF THE FOLLOWING? Diabetes High Blood Pressure Abnormal Cholesterol Stroke Heart Disease Lung Disease Kidney Diseases Gastrointestinal Diseases Liver Diseases Pancreas Diseases Gallbladder Diseases Colon Polyps Musculoskeletal Diseases Joint Diseases Vascular Diseases Cancerous Diseases HAVE YOU BEEN EXPERIENCING ANY YES NO IF YES, PLEASE EXPLAIN HOW OFTEN AND WHEN SYMPTOMS OCCUR OF THESE SYMPTOMS? Eyes: Jaundice/Double vision Ear, Nose & Throat: Sore throat/ Nasal congestion/Ear pain Respiratory: shortness of breath/ Cough/sputum(phlegm)/Wheezing/ Blood in sputum (Hemoptysis) Cardiovascular: Chest pain/ Palpitation/Irregular heart beat/ Calf pain/ Claudication ( Pain when walking)/Leg swelling (edema) Skin: Rash/Abrasions/Discoloration Neurologic: Tingling/Abnormal balance Psychiatric: Anxiety/ Depression/ Mania/ Suicidal/ Delusional/Hallucinational Gastrointestinal and Constitutional Weight loss Weight gain Eating Disorders Difficulties Swallowing Painful swallowing Regurgitation Heartburn Nausea Vomiting Vomiting Blood Abdominal Distention (swelling) Patient Name: HAVE YOU BEEN EXPERIENCING ANY OF THESE SYMPTOMS? Bloating Diarrhea Constipation Blood in stool Change of color in stool Stool Inconsistency Itching Regular Bowel Movement Hemorrhoids Other GI symptoms not listed FAMILY HISTORY Do you have family history of any of the following? History of Colon Cancer History of Colon Polyp Date: YES NO YES Referring Physician: IF YES, PLEASE EXPLAIN HOW OFTEN AND WHEN SYMPTOMS OCCUR NO Relative History of Other GI malignancies (Pancreas, Liver, Gallbladder, Stomach, Esophagus, Intestine) Other past family history PLEASE LIST ALL PAST SURGICAL HISTORY/HOSPITALIZATIONS Date: 1. 2. 3. 4. 5. PAST PROCEDURE HISTORY Colonoscopy Upper Endoscopy ERCP YES/NO YES/NO YES/NO Year done: Year done: Year done: Please provide your Pharmacy Name and Address: ______________________________ ______________________________ ______________________________ Pharmacy Phone#: (____)__________ Fax: (____)__________ Findings: Findings: Findings: Patient Name: ___________________________ DOB: ____________ ALLERGIES (Yes/No) Referring Physician: ____________________ If Yes: List All Allergies including: Medication, Food, and Environmental Brief description of allergic reaction: 1. 2. 3. 4. 5. List All CURRENT Medications and Dosages: Please make sure to include the following if any: NSAID’s use: (Aspirin, Naproxen, Motrin, Ibuprofen, Aleve) Anticoagulation/Blood Thinners: ( Plavix, Heparin, Warfarin) Laxatives, Herbal Medicine, Pain Medications Medication name: Dose: Reason: 1 1. 2. 3. 4. 5. 6. 7. List All DISCONTINUED Medications and Dosages: Medication name: Dose: Reason: 1. 2. 3. 4. SOCIAL HISTORY Do you drink alcohol? Are you a smoker? Do you use illicit Drugs? YES/NO YES/NO YES/NO If Yes, How Often? If Yes, How Often? If Yes, How Often? Advanced GI Associates, LLC Dr. Homayoon Mahjoob, M.D., M.S.P.H. 12150 Annapolis Road Suite 312 Glendale, MD 20707 Office: (301) 352 7771 Fax: (800) 681 5070 Consent for Release and Use of Confidential Information I, hereby (Name of Patient or Authorized Agent) give my consent to Advanced GI Associates, LLC., to use or disclose, for the purpose of carrying out treatment, payment, or health care operations, all information contained in the patient record of . I understand that this consent is valid until it is revoked by me. I understand that I may revoke this consent at any time by giving written notice of my desire to do so, to the physician. I also understand that I will not be able to revoke this consent in cases where the physician has already relined on it to use or disclose my health information. Written revocation of consent must be sent to the physician’s office. I understand that I have the right to request that the practice restricts how my individually identifiable health information is used and/or disclosed to carry out treatment, payment or health operations. I understand that the practice does not have to agree to such restrictions, but that once such restrictions are agreed to, the practice and their agents must adhere to such restrictions. Name: Signed: If not the patient, please specify your relationship to the patient Date: