PATIENT INFORMATION SHEET


NAME:_______________________________________________DOB: __________ AGE: _______


STREET ADDRESS: ________________________________________________________________


TOWN: _____________________________________ STATE: __________ ZIP: _____________


SS#: ________________ PRIMARY CARE PHYSICIAN: __________________________________


HOME TELEPHONE #: ______________________ WORK TELEPHONE #: _____________________


CELL PHONE #: ______________________ EMAIL ADDRESS: ____________________________


REFERRING PHYSICIAN: ___________________________________________________________


NAME OF EMPLOYER: _______________________________TOWN: _________________________


INSURANCE COMPANY NAME: ________________________________________________________


POLICY #: _____________________________ GROUP #: _______________________________


POLICYHOLDER'S NAME: ___________________________________________________________


IF COVERED UNDER SPOUSE'S MEDICAL INSURANCE IN ADDITION TO YOUR OWN POLICY, PLEASE
FILL OUT BELOW


NAME OF INSURANCE COMPANY: _____________________________________________________


POLICY #: ______________________________ GROUP #: ______________________________


SPOUSE'S NAME: _________________________________________________________________


PLEASE SIGN THE BOTTOM OF THIS PAGE. THIS WILL AUTHORIZE ATTLEBORO GASTROENTEROLOGY
FOR BENEFITS AND PAYMENTS FROM INSURANCE COMPANIES FOR SERVICES RENDERED. THIS ALSO
AUTHORIZES ATTLEBORO GASTROENTEROLOGY TO RELEASE YOUR MEDICAL RECORDS TO YOUR
INSURANCE COMPANY WHEN REQUESTED BY THEM FOR PAYMENT OF CLAIMS. YOUR SIGNATURE BELOW
ALSO INDICATES THAT IF AND WHEN YOUR INSURANCE COMPANY DENIES PAYMENT FOR A SERVICE
OR PROCEDURE, WHICH YOU AND YOUR DOCTOR DEEM MEDICALLY NECESSARY, YOU WILL ASSUME
THE RESPONSIBILITY FOR A TIMELY PAYMENT.


SIGNATURE: ___________________________________ DATE: ___________________________






PLEASE TAKE A MOMENT TO FILL OUT THIS HEALTH INFORMATION FOR YOUR CHART.



PLEASE LIST YOUR CURRENT MEDICATION & DOSES: ___________________________________

________________________________________________________________________________


DO YOU HAVE KNOWN ALLERGIES? ___________________________________________________

________________________________________________________________________________


PLEASE LIST YOUR SURGERIES & DATES: ____________________________________________

________________________________________________________________________________


PLEASE LIST ANY PAST OR CURRENT MEDICAL PROBLEMS (EXAMPLE: HIGH BLOOD PRESSURE, 

HEAR TROUBLE, DIABETES, ETC.) __________________________________________________

________________________________________________________________________________


DO YOU SMOKE?			YES			NO


DO YOU DRINK ALCOHOL?		YES			NO


HOW MUCH PER DAY DO YOU DRINK? _________________________________________________


CURRENT MEDICAL PROBLEM THAT BRINGS YOU TO OUR OFFICE TODAY: ___________________

________________________________________________________________________________

________________________________________________________________________________


PLEASE LIST ANY FAMILY HISTORY THAT IS PERTINENT (CANCER OF COLON, LIVER OR 

STOMACH, ANY FAMILY MEMBER WITH HISTORY OF POLYPS, COLITIS, ILEITIS, 

HYPERTENSION, DIABETES OR HEART DISEASE.) ______________________________________

________________________________________________________________________________

________________________________________________________________________________



PATIENT SIGNATURE & DATE: ___________________________________________________