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Our Providers
Dr. Michael Goodman
Caitlin Grant Collier, FNP
Treatment Info
Common GI Diseases and Disorders
Preps and Procedures
Understanding Colonoscopies
Infliximab Treatment for Crohn’s & Colitis
In-Office Endoscopy Suite
Patient Forms
Patient Bill of Rights
Patient Packet
Patient Satisfaction Survey
FAQs
General FAQ
Billing FAQ
Our Providers
Dr. Michael Goodman
Caitlin Grant Collier, FNP
Treatment Info
Common GI Diseases and Disorders
Preps and Procedures
Understanding Colonoscopies
Infliximab Treatment for Crohn’s & Colitis
In-Office Endoscopy Suite
Patient Forms
Patient Bill of Rights
Patient Packet
Patient Satisfaction Survey
FAQs
General FAQ
Billing FAQ
Medical Assessment - Conditions
(Form 3 of 6)
Name
Date of Birth
Form Entry Date
Please let us know about any experience you have had with the issues below.
Give additional details as appropriate.
Anesthesia Reactions
Yes
No
Additional Details
Surgery Complications
Yes
No
Additional Details
Breathing problems
Yes
No
Additional Details
Diabetes
Yes
No
Additional Details
Blood Pressure problems
Yes
No
Additional Details
Heart problems
Yes
No
Additional Details
Mitral valve prolapse
Yes
No
Additional Details
Do you take antibiotics before dental or other procedures?
Yes
No
Additional Details
Glaucoma
Yes
No
Additional Details
Seizures
Yes
No
Additional Details
Hepatitis/yellow jaundice
Yes
No
Additional Details
History of hip or knee joint replacement
Yes
No
Additional Details
Any pins or screws in your body?
Yes
No
Additional Details
Any recent antibiotic use?
Yes
No
Additional Details
Ever been treated for H. pylori bacteria?
Yes
No
Additional Details
Have you had any cancer?
Yes
No
Additional Details
Blood transfusions
Yes
No
Additional Details
Any recent stress?
Yes
No
Additional Details
Any emotional problems (depression, panic attacks, etc.)?
Yes
No
Additional Details
Any history of alcohol or drug abuse?
Yes
No
Additional Details
Have you ever been to pain management?
Yes
No
Additional Details
Are you taking any diet pills?
Yes
No
Additional Details
Are you HIV Positive?
Yes
No
Additional Details
Have you ever had chemotherapy or radiation therapy?
Yes
No
Additional Details
Date of last flu shot
Date of last pneumonia shot
Other Conditions
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