welcome to florida digestive specialists

Florida Digestive Specialists Gastroenterology and Liver Disease Management

Over 30 Years of Service

5651 49th Street North, St. Petersburg, FL 33709 Phone: (727) 443-4299

1417 S. Belcher Road, Suite A Clearwater, FL 33764

Fax: (727) 443-0255

Welcome to Florida Digestive Specialists

We know that as a patient you have many options for your Gastroenterology and Liver Disease Management Care and we thank you for choosing our practice to help you with your continued care.

I (Patient Name), give permission for Florida Digestive Specialists (FDS) to provide me medical care and treatment. I also allow FDS to file insurance benefits on my behalf, to pay for the care and treatment I receive.

I understand that: I must provide a current photo ID or Driver’s License at time of service, without one, I will not

be seen All Copays and Co-Insurances are due upon check in or my appointment will be cancelled If I have no insurance, full payment is due at time of service, unless prior arrangements have

been made with our office.

Our practice accepts most insurances. However, it is the patient’s responsibility to verify coverage for our facilities. Please check with your insurance company to verify your coverage, copay, deductible and co- insurance fees. Patients are responsible for all services not covered by your healthcare insurance.

Please advise our office whenever you have a change of address, phone number or insurance coverage.

If a patient misses 3 appointments without contacting our office 24 hours prior to appointment time, you will be discharged from the practice.

Patients Name: DOB:

Patients Signature: Date:





Fax: (727) 443-0255

Patient Name: DOB:

Have you had an upper endoscopy in the past 30 days? Where When Have you had a colonoscopy? Where When Do you have relatives with colon cancer/colon polyps? Relation Have you had intestinal surgery within the last 3 months? If yes, please describe:

Have you had any surgeries within the past 5 years? If yes, please describe:

Medications Currently Taking: Name Dose How Often Reason

** Have you used any drugs other than what’s prescribed to you in the past 6 months? No or Yes If yes, what did you use?

ALLERGIES Please list any allergies and their side effects/reactions: (Including Eggs, Latex, Medications, etc.)

Allergy: Side Effects/Reactions:

YES / NO





Fax: (727) 443-0255

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information (PHI). I understand that this information can and will be used to:

Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who

may be involved in my treatment directly and indirectly Obtain payment from third-party payers Conduct normal healthcare operations such as quality assessments and physician certifications

I received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my PHI. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices.

Patient Name: Date:

Patient Signature: __________________________________ Phone number:__________________ May we leave a voicemail? ____ Yes ____ No

Please list below any family members/friends which may receive information regarding your diagnosis, condition, plan of care, medications, test results, appointments and anything else that is considered patient condition, treatments or payment related.

Name: Relationship:

Home Phone: Cell Phone: May we leave a voicemail? ____ Yes ____ No

Name: Relationship:

Home Phone: Cell Phone: May we leave a voicemail? ____ Yes ____ No

Patient Signature: Date:





Fax: (727) 443-0255

REVIEW OF SYSTEMS

Heartburn O Yes O No General/Constitutional: Uncontrolled Bowel Habits O Yes O No

Nausea O Yes O No Appetite Reduced O Yes O No Pain when Swallowing O Yes O No Fatigue O Yes O No Rectal Bleeding O Yes O No Fever O Yes O No Vomiting O Yes O No Night Sweats O Yes O No Hematology: Weight Gain O Yes O No History of Blood Transfusion O Yes O No Weight Loss O Yes O No Abnormal Bleeding O Yes O No

HEENT/Neck: Anemia

Easy Bruising O Yes O Yes

O No O No

Change in Vision O Yes O No Loss of Hearing O Yes O No Genitourinary: Hoarseness O Yes O No Passing Stool/Gas from Vagina O Yes O No Mouth Sores O Yes O No Blood in Urine O Yes O No Sore Throat O Yes O No Pain with Urination O Yes O No Swollen Lymph Nodes O Yes O No Urinary Incontinence O Yes O No

Endocrine: Excessive Thirst O Yes O No Diabetes O Yes O No Thyroid Problems O Yes O No

Vaginal Bleeding O Yes O No

Musculoskeletal: Joint Swelling O Yes O No Arthritis O Yes O No Bone Pain O Yes O No

Respiratory: Asthma

O Yes

O No

Muscle Aches O Yes O No

COPD/OSA (use of C-PAP machine) O Yes O No Dermatologic: Cough O Yes O No Itching O Yes O No Coughing up blood O Yes O No Jaundice (yellowing of skin and/or eyes) O Yes O No Shortness of Breath O Yes O No Rash O Yes O No Wheezing O Yes O No Skin Cancer O Yes O No

Cardiovascular: Neurologic: Chest Pain O Yes O No Loss of Strength/Sensation

O Yes

O No

Palpitations O Yes O No Confusion O Yes O No PND (shortness of breath during sleep) O Yes O No Dizziness O Yes O No

Gastrointestinal: Abdominal Pain O Yes O No Black Stools O Yes O No Bloating O Yes O No Change in Bowel Habits O Yes O No Constipation O Yes O No

Headache O Yes O No Seizures O Yes O No Strokes O Yes O No Tingling/Numbness O Yes O No

Psychiatric:

Diarrhea O Yes O No Difficulty swallowing O Yes O No Feels full fast after eating O Yes O No

Anxiety O Yes O No Depression O Yes O No Eating Disorder O Yes O No





Fax: (727) 443-0255

Date: Social History

Patient Name: DOB:

These questions are only intended to assist in your healthcare. Please circle or check: Do you smoke cigarettes? No Yes Do you drink alcohol currently? No Yes

If yes, how much do you drink? (1 serving=12oz beer, 5oz wine or 1.5oz liquor) please check:

Occasional use-less than 3 servings per month Less than 7 servings per week More than 2 servings per day More than 7 servings per week

If these do not apply, please indicate another amount:

Have you participated in Recreational Drug use? No or Yes If so, what kind?





Fax: (727) 443-0255

Anesthesia Pre-op Questionnaire

Patient Name:

Gender: Age:

BMI:

Please Fill Out This Form Completely! Do you currently have or have had a history of any of the following? Cardiovascular

☐ Y ☐N Shortness of breath walking 2-3 blocks # of blocks you can walk # of stairs you can climb

☐ Y ☐N Pacemaker/Defibrillator Type:

Date last integrated:

☐ Y ☐N Heart Attack less than 6 months ago ☐ Y ☐N Have A-fib or other abnormal rhythm ☐ Y ☐N Heart Transplant ☐ Y ☐N Heart Surgery or stents

☐ Less than 6 months ago ☐ Y ☐N Chest Pain ☐ Y ☐N Congestive Heart Failure/ CHF ☐ Y ☐N Ventricular Assist Device/ VAD ☐ Y ☐N Heart Disease/ Coronary Artery Disease ☐ Y ☐N High Blood pressure

Pulmonary ☐ Y ☐N Pulmonary Hypertension ☐ Y ☐N Lung Transplant ☐ Y ☐N Part of lung removed/ resected ☐ Y ☐N Do you use oxygen at home?

☐ Daytime ☐Nighttime ☐ Y ☐N Sleep Apnea

☐ Severe ☐Moderate ☐Mild ☐ Y ☐N Do you use a CPAP/ BiPAP? ☐ Y ☐N COPD/Emphysema/Asthma How often do you use a rescue inhaler?

Hematologic/ Neurologic ☐ Y ☐N Stroke/ Mini Stroke / TIA

☐ Less than 6 months ago ☐ Have weakness

☐ Y ☐N Seizures ☐ Daily ☐Weekly ☐Monthly

☐ Y ☐N Bleeding/ Clotting disorder ☐ Y ☐N Blood clot less than 12 months ago? ☐ Y ☐N Taking blood thinners? (other than Aspirin)

Renal/Endocrine/Gastrointestinal ☐ Y ☐N Kidney problems/ Failure

☐ Dialysis? What Days? ☐ Y ☐N Kidney Transplant? What year? ☐ Y ☐N GERD/ Acid reflux ☐ Y ☐N Liver Disease/ Hepatitis ☐ Y ☐N Diabetes

☐ on insulin? Anesthesia Problems ☐ Y ☐N Post-op nausea or vomiting ☐ Y ☐N Prolonged sedation/ intubation ☐ Y ☐N Awareness under anesthesia ☐ Y ☐N Have you been told you were difficult

to place a breathing tube? ☐ Y ☐N Malignant Hyperthermia

☐ You ☐Family Member

Miscellaneous ☐ Y ☐N Fever > 100 F in the past month ☐ Y ☐N Respiratory infection/ Pneumonia

In the past month? ☐ Y ☐N Use of Drugs?

☐ Marijuana ☐Crack/Cocaine ☐ methamphetamines ☐IV Drugs

☐ Y ☐N History of smoking/ current smoker ☐ Y ☐N Alcohol use of 2 or more drinks per day ☐ Y ☐N HIV ☐Y ☐N TB Patient Signature: Date:

welcome to florida digestive specialists

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