Microsoft word - patient profile 9-17b

Patient Profile
Please submit this form to our Corporate office at: Raleigh Endoscopy Center 2417Atrium Dr Ste 101 Raleigh, NC
27607 or fax 919-791-2061

Name (print):________________________________ Date of Birth:___________ Procedure Date:____________
Emergency Contact:____________________________Relationship:_______________ Phone #:______________
Primary Care Physician:_________________________Reason for Procedure:_____________________________

Drug Allergies & Reaction:____________________________________ LATEX ALLERGY: Y / N
Medicine & Dose-Reason Taken Medicine & Dose-Reason Taken Medicine & Dose-Reason Taken
___________________________ _________________________ _________________________ ___________________________ _________________________ _________________________
___________________________ _________________________ _________________________
BLOOD THINNERS: Do You Take: Aspirin, BC powder, Aleve, Motrin, Ibuprofen, Vitamin E
Blood Thinners Such As: Coumadin Warfarin Plavix Levonox or Ticlid? Y / N
HEIGHT__________ WEIGHT____________
PLEASE CIRCLE IF YOU HAVE OR HAVE HAD ANY OF THE FOLLOWING: CARDIAC: High Blood Pressure High Cholesterol Mitral Valve Prolapse Irregular Heart Rate Angina
Heart Disease (TYPE)____________________ Stent Pacemaker Heart Attack (MI) Congestive Heart Failure
PULMONARY: Asthma Emphysema COPD Sleep Apnea
GI: Acid Reflux Barrett’s Esophagus Colitis / Crohn’s Colon Polyps Colostomy Ulcers
Diverticulosis / Diverticulitis Colon Cancer
GU: BPH Urinary Incontinence
KIDNEY/ENDOCRINE: Diabetes Kidney Failure / Dialysis Thyroid Problems
NEUROLOGIC/MUSCULAR:Stroke Parkinson’s Migranes TIA’S Seizures: Date Of Last Seizure________
PSYCHOLOGIC: Depression Anxiety Mental Illness (type)_______________________________________
AUTOIMMUNE: Rheumatoid / Osteo Arthritis Lupus HIV/AIDS
Anemia Bleeding Disorder Cancer (type): ______ Radiation / Chemotherapy Date: _______________
Pregnant Y / N Breast Feeding Y / N
OTHER ILLNESSES NOT LISTED:________________________________________________________________
Do you have to take antibiotics before a medical or dental procedure? Y / N . FAMILY MEDICAL HISTORY
LIST FAMILY MEMBER THAT HAD THE FOLLOWING DISEASE (Immediate family only) Cancer: Esophageal_____________ Colon____________ Stomach______________OTHER___________________ Diabetes_______________ High Blood Pressure ______________ Heart / Lung Disease______________________ ENDOSCOPY/SURGICAL HISTORY
________________________________________ __________________________________________ ________________________________________ __________________________________________ ________________________________________ __________________________________________ Have you ever had any problems with anesthesia? Y / N __________________________________________

Do You Smoke? Y / N # Packs/day________ Smokeless Y / N (amount)_______________ Alcohol use: Never Occasionally Daily (# drinks/day)_________________ Rev 09-09


Microsoft word - nbac intake form.doc

Dear Doctor: Thank you for referring your patient to the Newport Beach Anticoagulation Clinic (NBAC). Please complete and sign the order below. Your signature indicates that you are requesting the Anticoagulation staff to manage your patient according to Newport Beach Anticoagulation Clinic Coumadin Titration – Standard Procedure. If your patient is unable to comply with the clinic protocol (i

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