Patient Forms 1Patient Information2Employment & Guardian Information3Health History4Family/Patient History5Insurance Information6Questionnaire7HIPPA Compliance Do you have an upcoming appointment?* Yes - I have a scheduled appointment No - I do not have a scheduled appointment Date of Upcoming Appointment* MM slash DD slash YYYY Patient InformationName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home or Cell Phone Number*Work Phone NumberEmail* Sex*Select oneFemaleMaleDate of Birth* MM slash DD slash YYYY AgeSocial Security Number Marital Status*Select oneMarriedSingleDivorcedWidowedWidower Emergency ContactsContact Name Relationship PhoneReferring Physician* Referring Physician Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Employer DetailsAre you Employed* Yes No Employer Name PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Responsible Party (complete if patient is under 18 years of age)Name First Last Home or Cell Phone Number Pharmacy DetailsPharmacy Name Pharmacy Phone Number Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Health HistoryHeight Weight Allergy General Dizziness Fainting Fever Headache Sleep loss Weight gain Weight loss Nervousness Skin Bruise easily Hives Itching Changes in mole Rash Gastrointestinal Blood in stool Bowel changes Rectal bleeding Stomach pain Haemorrhoids Diarrhoea Constipation Indigestion Gas Increase in appetite Loss of appetite Blood in vomit Nausea Excessive hunger Vomiting Men Erectile dysfunction Discharge from penis Lump in testicles Others Others WomenLast menstrual period Last mammogram Last pap smear Cardiovascular High blood pressure Low blood pressure Irregular heart beat Swelling of ankles Poor circulation Rapid heart beat Pain/Numbers Arms Back Feet Fingers Hands Hips Legs Neck Shoulders Vaccinations Flu Vaccine Pneumococcal Hep A Hep B HPV Meningococcal Heent Vision halos Double vision Blurred vision Vision flashes Difficulty swallowing Hoarseness Persistent cough Eye infections Sore throat Ear discharge Ear infection Ear ache Hearing Loss Ringing in ears Please select all that apply to you Aids Alcoholism Anaemia Anorexia Appendicitis Arthritis Asthma Cancer Chicken pox Diabetes Drug dependency Emphysema Epilepsy Glaucoma Hepatitis Hernia Herpes High Cholesterol HIV positive Kidney disease Tuberculosis Pneumonia Polio Prostrate problems Psychiatric care Rheumatic fever Stroke Depression Check if any of your Relatives (and their relation to you) have the following conditions:Arthritis Heart disease Asthma, hay fever High Blood pressure Colon Cancer Kidney disease Other Cancer Tuberculosis Diabetes Stroke Gout Chemical dependency Occupation: lifting involved: Exercise:How often do you exercise? Smoking: Yes No Packs per day. Start Date MM slash DD slash YYYY Quit Date: MM slash DD slash YYYY Recreational drugs: Yes No Alcohol: No Yes Amount: Coffee: No Yes # of cups a day. Tea: No Yes # of cups a day. Hospitalizations: / SurgeryHospitalization/Surgery Yes No YearReasonHospital Pregnancy history:YearComplications Are you on Medication* Yes No Prescribed Medications: Dose/Frequency: Over the Counter Supplements/Medications: Have you ever had a blood transfusion? Yes No Date: MM slash DD slash YYYY Injury Related InformationType of Insurance* Insurance Related InformationIs your condition related to an injury from?* Work Auto Private Injury No Injury Date of Injury* MM slash DD slash YYYY Employer at Time of Injury* Primary Insurance DetailsPrimary Insurance Insured Name First Last Date of Birth MM slash DD slash YYYY Policy# Group# Secondary Insurance DetailsSecondary Insurance Insuranced Name First Last Date of Birth MM slash DD slash YYYY Policy# Group# Upload Front and Back of Insurance Card Drop files here or Select files Max. file size: 64 MB, Max. files: 3. * I understand that I am financially responsible for all the charges for services to me, including the balance remaining after payment of possible insurance benefits. I am responsible to pay the deductible, co-insurance portion within thirty days of the office visit, and I authorise the release of any medical information necessary to process the insurance claim(s).Patient Rights and Responsibilities Pre-colonoscopy questionnaireHT: WT BMI 1. Any recent hospitalizations: Yes No If yes, give reason:2. Health History Changes: Yes No If yes, give reason:3. Any surgeries: Yes No If yes, give reason/any problem with surgery:4. Family history of colon cancer or polyps: Yes No If yes, what type?5. Any new symptoms Yes No If yes, explain.6. Last menstrual period Pregnancy urine test done Yes No If yes, explain.7. Tubal ligation Yes No Hysterectomy Yes No 8. History of heart surgery Yes No Pacemaker Yes No Valve replacement Yes No Stent placement 9. Hx of mitral valve proposed Yes No 10. Hx joint replacement surgery Yes No If yes, what type? Any MedicationsList Dosages Anticoagulants(blood thinner) Coumadin Heparin Lovenox Aspirin Plavix Xarelto OTC Medications 12. Allergy 13. Any current symptomsWeight loss Yes No Fever Yes No Abdominal pain Yes No Nausea Yes No Vomiting Yes No Difficulty in swallowing Yes No 14. Any problems with anaesthesia in the past? Yes No If yes, explain.15. Did you have colonoscopy or endoscopy previously? Yes No If yes: Where/When:16. Where you able to tolerate bowel cleansing preparation without any difficulties? Yes No If yes, explain.17. Do you have any living will, medical power of attorney, or other directive that could affect your care? Yes No If yes, please provide details of such information. I certify that the information that I have provided is correct to the best of my knowledge. I will not hold the Doctor or any staff member responsible for any errors or omissions that I may have made in the completion of this form.This notice describes how medical Information about you may be used and disclosed and how you can get access to this information.please read it carefully The law requires our medical practice (Suriya V. Sastri, M.D.) to protect the privacy of your medical information. This notice explains how our medical practice can use or share the medical information that our practice has about you or your family. It also explains your rights. For many people, third party insurance carriers, Medicare, or Public Aid (IDPA) pay for all health benefits and prescription drugs. Our medical practice must receive and keep your medical information so you can have these benefits. Our medical practice may contract with other organizations or individuals to help provide your health benefits. These contractors may also receive and keep your medical information Starting April14, 2003, we must follow this Notice until it is replaced. We can change the terms of this Notice at any time. If we change this Notice, we will send a new Notice to all persons enrolled at that time. We can make the new changes apply to all your medical information kept by us before and after the date of the new Notice. The Notice is posted at our medical office at 6900 Madison Street, Willowbrook, Illinois, 60527. We may use or share your medical information without your permission for the reasons below. So, you can get medical care. For example, we may share your medical information with your doctor or pharmacy so that they can give you medical care and the right medicine. So, medical bills can be paid. For example, we may use and share your medical information so your doctor can send a bill to your insurance carrier and so your insurance can pay your medical bills. We may also use or share your medical information to recover payment from other medical insurance or benefits you may have. So, our medical practice can perform its duties. For example, we may use or share your medical information with the referring physicians and other physicians coordinating your medical care, to assess quality of care; to determine who is eligible for medical benefits; to manage your care, or for audits. To tell you about other health services. For example, we may call or write to tell you about treatment options or other health-related services. To comply with the law. For example, the law requires us to allow the U.S. Department of Health and Human Services or other related agencies to audit our records. We may share your medical information to comply with other laws. For other reasons. Examples include: To comply with legal proceedings, such as a court or administrative order or subpoena To enforce other laws or protect someone's health and safety So a family member, friend, or other person can help you to get or pay for your health care So a personal representative you appoint or a court appoints for you can help you get health benefits To support research, as long as the information will be protected by the researchers So a coroner or medical examiner can identify a deceased person or cause of death or so a funeral director can arrange burial To support an organ procurement organization in limited circumstances To protect you against a serious threat to your health or safety or to the health or safety of others To support a government agency or hospital overseeing health care or monitor disease incidence programs For lawful national security purposes For public health purposes For military purposes, if you are a member of the armed forces. Our medical practice will not use or share your medical information for any other reason unless you give us written permission. You may withdraw your permission in writing at any time. However, if we have used or shared your information for a long-term project like a research study, we may continue to use or share your information for that purpose only. Your permission for us to use or share your information will end when our medical practice gets your written notice to withdraw you permission. Your Rights: You may ask our medical practice to do any of the following if you ask in writing. We will decide if it can do what you want it to do. We will write to tell you what it decides. You may ask us not to use or share your medical information. We do not always have to agree. You may ask us to contact you about your medical information privately in a different way or at a different place than we are currently doing. We do not always have to agree, unless the change is necessary to protect you, and we can still be paid for your medical bills. When you write to ask for this change, you must tell us how to contact you in private. You may ask to see or get copies of your medical information. You may be charged a small fee for copies. You may ask us to correct your medical information. We do not always have to agree to make the change. You may ask for a list of the ways our medical practice or its contractors shared your medical information for up to 6 years. We can tell you this for information that it shared on or after April, 2003. You may write to ask us to send you another copy of this Notice. If you want any of these things, contact our medical practice at the address below. We will help you make your written request. Complaints: If you believe our medical practice has not protected your right to privacy, you have the right to complain to us or to the Secretary of the U.S. Department of Health and Human Services. You may file a complaint with us at the address below. We will not hold it against you if you file a complaint. Privacy Officer: To get more copies of this Notice or more information about our privacy practices or your rights, or to file a complaint, contact the Privacy Officer at the following address: Suriya Sastri. MD6900 Madison StreetWillowbrook, IL 60527* I read this document carefully. Signature*
