Question Title * 1. Amarillo Surgical Group Doctor Dr. Shane Holloway Julie Hampton, NP-C Dr. Chance Irwin Dr. Christopher Kolze Dr. Sam Kirkendall Dr. David Langley Dr. Michael Lary Dr. John McKinley Dr. Erica Wheat Question Title * 2. Date Date Date Patient Information Question Title * 3. Patient Name Question Title * 4. Date of birth Date Date Question Title * 5. Patient Information Age Address City State Zip Home Phone # Work # Cell # Email Address Gender (Male/Female) Employer Additional contact Question Title * 6. Additional contact information Name Relationship to patient Home phone # Work # Cell # Responsible party’s information (if different from patient): Question Title * 7. Name Question Title * 8. Date of Birth Date Date Question Title * 9. Responsible Party’s Information (if different from patient) continued Age Address City State Zip Home Phone # Work # Cell # Employer Relationship to patient Visit Information Question Title * 10. Visit Information What problem are you here for today? Primary care provider? Referring provider (if not PCP) List any diagnostic tests related to problem (include date and location) Consent to Release Information Question Title * 11. Consent to Release Information Signature of patient or guardian Date Printed Name Allergies Question Title * 12. Allergies Please list any allergies to medications (include reaction if known) Are you allergic to CT scan contrast (include reaction if known)? Pharmacy Question Title * 13. What is your preferred Pharmacy (name and address)? Please list all medications you are taking (include prescribed and over the counter medicines) Question Title * 14. Medication Medication Name 1 Dose Frequency Medication Name 2 Dose Frequency Medication Name 3 Dose Frequency Medication Name 4 Dose Frequency Medication Name 5 Dose Frequency Medication Name 6 Dose Frequency Medication Name 7 Dose Frequency Medication Name 8 Dose Frequency Medication Name 9 Dose Frequency Family History (check all that apply) Question Title * 15. Mother Asthma Diabetes Heart Disease Hypertension Stroke Cancer Other (please specify) Question Title * 16. Father Asthma Diabetes Heart Disease Hypertension Stroke Cancer Other (please specify) Question Title * 17. Sister Asthma Diabetes Heart Disease Hypertension Stroke Cancer Other (please specify) Question Title * 18. Brother Asthma Diabetes Heart Disease Hypertension Stroke Cancer Other (please specify) Question Title * 19. Daughter Asthma Diabetes Heart Disease Hypertension Stroke Cancer Other (please specify) Question Title * 20. Son Asthma Diabetes Heart Disease Hypertension Stroke Cancer Other (please specify) Question Title * 21. Family History Adopted Family history unknown Medical History (check all that apply, please provide date of diagnosis if known and any other details): Question Title * 22. Anal fissure Yes Details Question Title * 23. Breast biopsy Yes Details Question Title * 24. Breast cancer Yes Details Question Title * 25. Breast mass Yes Details Question Title * 26. Cholelithiasis Yes Details Question Title * 27. Colon cancer Yes Details Question Title * 28. Colon polyp Yes Details Question Title * 29. Diverticulitis Yes Details Question Title * 30. Fibrocystic breast Yes Details Question Title * 31. Genetic testing Yes Details Question Title * 32. GI Bleeding Yes Details Question Title * 33. Liver Cancer Yes Details Question Title * 34. Pancreatitis Yes Details Question Title * 35. Rectal bleeding Yes Details Question Title * 36. Stomach Cancer Yes Details Question Title * 37. Thyroid nodule Yes Details Question Title * 38. Wound dehiscence Yes Details Question Title * 39. Wound infection Yes Details Next
