Patient History Please enable JavaScript in your browser to complete this form.Name *Address *City *Zip *Phone Number *EmailLast 4 of SSN *Date of Birth *Primary Care PhysicianReason for Visit (List Symptoms) *Pharmacy NamePharmacy Phone NumberCurrent MedicationsList any blood thinners (including aspirin)Drug AllergiesMedical HistoryHigh Blood PressureDiabetesHigh CholesterolThyroid DiseaseCOPDHeart Stent(s)Heart FailureAtrial FibrillationPacemakerDefibrillatorNoneSurgical HistoryGall BladderAppendixIntestinal or colon surgeryHysterectomyFamily HistoryColon CancerLiver DiseaseCrohns DiseaseColitisPancreatic CancerDo you smoke? *YesNoYears of SmokingPacks per dayDo you drink alcohol? *DailyWeekendsSociallyRarelyNeverLast ColonoscopyLocationColonoscopy FindingsLast EndoscopyLocation Endoscopy FindingsLast EUS or ERCPLocation CT ScanLocation Ultrasound ScanLocationPrimary InsuranceMember IDGroup #Name of InsuredRelation to PatientSecondary InsuranceMember IDGroup #Name of InsuredRelation to PatientAssignment of Insurance Information & Benefits/Release of Medical Information *I hereby authorize Gastroenterology Care LLC to administer/perform any medical and or surgical procedure deemed necessary, and authorize release of information needed to secure payment. I authorize that all benefits by my insurance company be paid directly to Gastroenterology Care LLC. Furthermore, I understand that I am responsible for all co-pays/co-insurance/deductibles and/or charges incurred that are not covered in full by my insurance. I hereby authorize the release of all applicable medical information, including & without limitation, copies of all records and test results produced to the designated attending, referral, and/or follow-up physicians and such other health care practitioners or organizations who/which will be providing subsequent care or treatment in connection with care provided by Gastroenterology Care LLC.E-Signature (Type Full Name) *Today's Date *MessageSubmit