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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 - Procedures and Lab Work
(Form 2 of 6)
Name
Date of Birth
Form Entry Date
Have you ever had any of the following x-rays of the stomach and/or colon?
Barium enema
Yes
No
Where/Doctor who ordered
Results
Date (approx)
Upper GI
Yes
No
Where/Doctor who ordered
Results
Date (approx)
Small bowel
Yes
No
Where/Doctor who ordered
Results
Date (approx)
Ultrasound of gallbladder
Yes
No
Where/Doctor who ordered
Results
Date (approx)
CT of abdomen
Yes
No
Where/Doctor who ordered
Results
Date (approx)
Hida Scan
Yes
No
Where/Doctor who ordered
Results
Date (approx)
Gastric emptying scan
Yes
No
Where/Doctor who ordered
Results
Date (approx)
MRI of the abdomen
Yes
No
Where/Doctor who ordered
Results
Date (approx)
Laboratory Work
Have you had any recent lab work done?
Yes
No
When?
Where?
Have you had a recent EKG?
Yes
No
When?
Where?
Have you ever had your throat, stomach or intestines looked at with a lighted scope?
Panendoscopy (stomach)
Yes
No
Where/Doctor
Date (approx)
Colonoscopy
Yes
No
Where/Doctor
Date (approx)
Flexible sigmoidoscopy
Yes
No
Where/Doctor
Date (approx)
ERCP
Yes
No
Where/Doctor
Date (approx)
Stretching of your esophagus
Yes
No
Where/Doctor
Date (approx)
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