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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 - Surgical
(Form 4 of 6)
Name
Date of Birth
Form Entry Date
Cardiac Surgery
Coronary Bypass
Yes
No
Date of Surgery
Place surgery performed
Surgeon
Coronary Stent
Yes
No
Date of Surgery
Place surgery performed
Surgeon
Pacemaker Insertion
Yes
No
Date of Surgery
Place surgery performed
Surgeon
Internal Defibrillator
Yes
No
Date of Surgery
Place surgery performed
Surgeon
Heart Valve Replacement
Yes
No
Date of Surgery
Place surgery performed
Surgeon
GI Surgery
Anal Fissure Repair
Yes
No
Date of Surgery
Place surgery performed
Surgeon
Colon Resection
Yes
No
Date of Surgery
Place surgery performed
Surgeon
Small Bowel Resection
Yes
No
Date of Surgery
Place surgery performed
Surgeon
Gastrectomy (Bilroth I or II)
Yes
No
Date of Surgery
Place surgery performed
Surgeon
Nissen Fundiplication
Yes
No
Date of Surgery
Place surgery performed
Surgeon
Gastric Banding
Yes
No
Date of Surgery
Place surgery performed
Surgeon
Gastric Bypass
Yes
No
Date of Surgery
Place surgery performed
Surgeon
Gallbladder
Yes
No
Date of Surgery
Place surgery performed
Surgeon
Hemoorhoidectomy
Yes
No
Date of Surgery
Place surgery performed
Surgeon
Orthopedic Surgery
Hip Replacement
Yes
No
Date of Surgery
Place surgery performed
Surgeon
Knee Replacement
Yes
No
Date of Surgery
Place surgery performed
Surgeon
Cervical Spine
Yes
No
Date of Surgery
Place surgery performed
Surgeon
Additional Surgery not specified above
Additional Surgery 1
Date of Surgery
Place surgery performed
Surgeon
Additional Surgery 2
Date of Surgery
Place surgery performed
Surgeon
Additional Surgery 3
Date of Surgery
Place surgery performed
Surgeon
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