Skip to content
(423) 267-5677
info@goodman-gi.com
Mon - Fri: 9:00 - 5:00
Search
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 - Medications and Allergies
(Form 6 of 6)
Name
Date of Birth
Form Entry Date
CURRENT:
Medications You Are Now Taking
(including any over the counter medications, hormones and birth control pills):
Drug
Dosage
Frequency
Drug
Dosage
Frequency
Drug
Dosage
Frequency
Drug
Dosage
Frequency
Drug
Dosage
Frequency
Drug
Dosage
Frequency
Drug
Dosage
Frequency
Drug
Dosage
Frequency
Drug
Dosage
Frequency
Drug
Dosage
Frequency
Drug
Dosage
Frequency
Drug
Dosage
Frequency
Drug
Dosage
Frequency
PAST:
Have you ever used any of the following medications on a regular basis?
(If ‘YES’, when, and did it work?)
Aspirin-containing medications
(Goodies, Excedrin, Aspirin, Alka-Selzer)
Yes
No
Details
Arthritis Medications
(Nsaids, Motrin, Ibuprofen, Advil, Aleve, etc.)
Yes
No
Details
Ulcer medications
(Prilosec, Prevacid, Aciphex, Tagamet, Protonix, Nexium)
Yes
No
Details
Stomach cramps medication
(Librax, Levsin, Donnatal, Hyoscyamine, Bentyl, NuLev, Zelnorm)
Yes
No
Details
Nerve Pills
(Xanax, Valium, Tranxene, Prozac, Zoloft, Paxil, etc.)
Yes
No
Details
Blood thinners
(Coumadin, Aspirin, Heparin, Xarelto, Plavix, Eliquis etc.)
Yes
No
Details
Anti Nausea medicines
(Phenergan, Zofran, Compazine)
Yes
No
Details
Iron tablets
Yes
No
Details
Laxatives
(Correctol, Senokot, Lactulose, Miralax, Kristalose, etc.)
Yes
No
Details
Herbal Product (Please specify product)
Yes
No
Details
Medication to help stomach empty faster
(Reglan, Propulsid, etc.)
Yes
No
Details
Fiber supplements
(Metamucil, Fiber-Con, Citrucel, Konsyl, Equalactin)
Yes
No
Details
Diet pills (Prescription or over-the-counter)
Please specify product
Yes
No
Details
Antacids
(Tums, Rolaids, etc.)
Yes
No
Details
Questran powder, Cholestid, Welchol
Yes
No
Details
Imodium, Lomotil or Pepto Bismol (for diarrhea)
Yes
No
Details
Asacol, Pentasa, Prednisone, Imuran, Purinethol, Methotrexate, Infliximab, Entyvio, Simponi, Humira, etc
Yes
No
Details
Accutane
Yes
No
Details
List pain medications you’ve used in the past
Allergies
(Including medications, x-ray dye, latex, tapes, foods, etc.)
Please list all allergies
Send
We use cookies to improve your experience on our site.
I understand and accept the use of cookies.
