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Valley Stream, NY

210 E. Sunrise Hwy., Suite 304, Valley Stream, NY 11581

516-265-7049

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Directions

Glendale, NY

78-01 Myrtle Ave., Glendale, NY 11385

516-265-7049

Enter your location for customized directions

Directions

Enter your location for customized directions

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516-265-7049

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Valley Stream, NY
Glendale, NY

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PATIENT QUESTIONNAIRE
Date*

Date Format: MM slash DD slash YYYY
Date of Birth

Date Format: MM slash DD slash YYYY
Age
Sex*
- Male
- Female
Name

First Name

Last Name
Address

Address

City

State

Zip
Email
Home Phone
Work
Cell
Social Security #
Medicare #
Primary Insurance*
Policy #
Name of Insured
Secondary Insurance
How did you hear About us?*
- Internet
- Friend/Family
- Doctor
- Zoc Doc
- Other
How did you hear About us – other
Primary care physician*
Martial Status
- Single
- Married
- Divorced
- Widowed
Employer
Occupation
Name of relative or friend
Phone

Please provide us with a telephone number of a relative or friend in case of emergency
**to be filled out in office**
ACKNOWLEDGEMENT OF RECIEPT OF NOTICE OF PRIVACY PRACTICES

GASTRCOARE LI RESERVES THE RIGHT TO MODIFY THE PRIVACY PRACTICES OUTLINED IN THE NOTICE
I have received a copy of the notice of privacy
Name of Patient
Signature of Patient
Date

Date Format: MM slash DD slash YYYY
Signature of Patient Respresentative
Relationship of Patient Representative to Patient

**to be filled out in office**
PERMISSION FOR DISCLOSURE OF HEALTH INFORMATION

Verification of Family / Friend
Date

Date Format: MM slash DD slash YYYY
Patient's Name
SS #
DOB
I give permission to GastroCare to discuss my private health information with the following people
TO DISCUSS MY PRIVATE HEALTH INFORMATION WITH
Name
Relationship to Patient
Name
Relationship to Patient
Name
Relationship to Patient
Name
Relationship to Patient
Name
Relationship to Patient
Name
Relationship to Patient
Signature of Patient :
You have the right to change this disclosure of medical history at any time, as long as you notify this office in writing
**to be filled out in office**
AUTHORIZATION FOR USE OF SIGNATURE ON FILE ASSIGNMENT OF BENEFITS

The undersigned hereby assigns all monetary benefits to be received by me from any individual, insurance company, or other person or organization as a result of any medical treatment or related services rendered to me by GastroCare LI, partial or full payment directly to GastroCare LI of such benefits.

I also authorize the release of any medical or other information necessary to process claims, I authorize payment of medical benefits to GastroCare LI physicians or suppliersfor all services rendered to me using “SIGNATURE ON FILE”. I request that payment of authorized Medicare benefits be made either to me or on my behalf to GastroCare LI for services furnised to me by the provider
I authorize any holder of medical information about me to release to the Health Care Financing Admininistration and its agents any information needed to determine these benefits of the benefits payable for related services.

This agreement is applicable to all services rendered by GastroCare LI at any future date so long as I do not cancel this agreement in writing.

Due to the ever-changing coverage of insurance plans, in order to accommodate all our patients, we will continue to participate with many managed care plans. However, you
are responsible for knowing the benefits and exclusions of your plan. It will be your responsibility to provide us with complete and accurate insurance information. As always, we will file the claim, but any procedure not covered by
your plan will be your responsibility.

Thank you in advance for your anticipated cooperation in this matter
Date

Date Format: MM slash DD slash YYYY
Patient name
Patient's Signature
Patient's Social Security Number

GastroCare LI – Medical History Form
First

Last
Date of Birth

Date Format: MM slash DD slash YYYY
Today's date

Date Format: MM slash DD slash YYYY
Race*
- White
- Hispanic
- Black/African American
- Asian
- Native Hawaiian
- American Indian/Alaska Native
- Other Pacific Islander
- Decline to report
Language*
- English
- Spanish
- Italian
- Hindi
- Russian
Reason for your visit today:
- Abdominal Pain
- Heartburn
- Ulcers
- Indigestion
- Crohn’s Disease
- Change in bowel habits
- Constipation
- Diarrhea
- Weight loss/gain
- Ulcerative colitis
- Decreased appetite
- Nausea
- Vomiting
- Difficulty swallowing
- H-Pylori
- Rectal Bleed
- Blood in Stool
- Hemorrhoids
- Anemia
- Jaundice
- Pancreatitis
- Hepatitis A B C
- Appendicitis
- Hernia
- Gall Bladder Disease
Other Reason
Please list all medication (prescriptions, OTC, Herbs, Etc) you are presently taking.
*** Please include Aspirin, Advil or any blood thinner type of medication***
Medication Name 1
Medication 1 dosage
Reason for taking medication 1
Medication Name 2
Medication 2 dosage
Reason for taking medication 2
Medication Name 3
Medication 3 dosage
Reason for taking medication 3
Medication Name 4
Medication 4 dosage
Reason for taking medication 4
Medication Name 5
Medication 5 dosage
Reason for taking medication 5
Medication Name 6
Medication 6 dosage
Reason for taking medication 6
Medication Name 7
Medication 7 dosage
Reason for taking medication 7
Medication Name 8
Medication 8 dosage
Reason for taking medication 8
Medication Name 9
Medication 9 dosage
Reason for taking medication 9
Medication Name 10
Medication 10 dosage
Reason for taking medication 10
Local pharmacy name*
Phone Number
Address

City

State
Does GastoreCare LI have permission to access your electronic Rx history?
- Yes
- No
Please list any allergies you have to medication, x-ray dyes, or other substances and reaction type
Patient Name
Date

Date Format: MM slash DD slash YYYY
Past Medical History
Please circle if you have had problems in the past or are presently diagnosed with any the following
- High Blood Pressure
- Diabetes Type I or II
- Hay fever
- Headaches
- Heart Disease
- Thyroid Disease
- Rheumatic Fever
- Anxiety
- Chest Pain
- Kidney Disease
- Skin Disease
- Depression
- Shortness of breath
- Kidney Stones
- Blood Disorders
- Alcohol Abuse
- Cancer
- Gout
- Bronchitis
- Drug Abuse
- Palpitations
- Urinary Disorders
- Pneumonia
- Veneral Disease
- Asthma
- Swollen Ankles
- Persistent Cough
- Hepatitis ABC
- Lightheadedness
- Arthritis
- Crohn’s Disease
- T.B
- COPD
- Low back Problems
- Celiac Disease
Other Past Medical History
Please list and supply dates of any surgeries
Family History
Gastrointestinal Disorders (polyps, cancer, etc)
All other cancers:
Other (diabetes, heart disease, etc)
Social History
Tobacco Use
- No
- Yes
Tobacco Use times per week
Alcohol Use
- No
- Yes
Alcohol Use Times per Week
Recreational drug use
- No
- Yes
Type(s) of recreational drugs used:
How often do you use recreational drugs
Eating Habits
- Healthy
- Fairly Healthy
- Mostly Junked Food
Inquiry
If you are interested in meeting with our Nutritionist on staff please notify the receptionist.
9/11 exposure?
- Yes
- No
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Location Info & Directions

Valley Stream, NY

210 E. Sunrise Hwy., Suite 304, Valley Stream, NY 11581

516-265-7049

Glendale, NY

78-01 Myrtle Ave., Glendale, NY 11385

516-265-7049

Connect with GastroCare LI

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