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PHYSICIANS
Rini Abraham, MD, PharmD
Aakash Aggarwal, MD
Oren E. Bernheim, MD
Robert Bleicher, MD
Andrew S. Boxer, MD
Neetu H. Chahil, MD
Bonnie Cheng, MD
Natasha Chhabra, MD
Aditi Chhada, MD
Elliot Coburn, MD
Steven David, MD
David M. Felig, MD
Steven D. Gronowitz, MD, FACG
Ashok Gupta, MD
Fahad M. Khan, MD
Natan Krohn, MD
Donald H. Kutner, DO
Matthew A. Kutner, DO
Steven Leibowitz, MD
Richard Lin, MD
Michael M. Mainero, MD
George Nikias, MD
Meet Parikh, DO
George N. Pavlou, MD
Haleh Pazwash, MD, FACG
David M. Pinn, MD
Ori A. Rackovsky, MD
Ravishankar ‘Ravi’ Ramamoorthy MD
Parthiv V. Raval, MD
Eric Rosendorf, MD
Joseph M. Roth, MD
Frank Ruiz, MD
Joseph G. Shami, MD
Jonathon Stillman, MD
Mark E. Tanchel, MD
Ariy Volfson, MD
Joseph Zangara, MD
Kenneth G. Zierer, MD
NURSE PRACTITIONERS
Patricia Kraycinovich, APN
Lisa Lamberti, NP
Diane Naraine, MSN, RN, FNP-C
Anna M. Nieves, NP
Alyssa Parrish MSN, RN, FNP-C
PHYSICIANS ASSISTANTS
Heather Schoenberger, PA
Gabrielle Wolfson, M.S., PA-C
CONDITIONS
Celiac Disease / Gluten Intolerance
Colon Cancer
Constipation, Diarrhea & Stool Abnormalities
Diverticulitis
Dumping Syndrome
Gallstones
Gastritis
Heartburn / (GERD)
Hemorrhoids
Hernia
Inflammatory Bowel Disease (IBD)
Irritable Bowel Syndrome (IBS)
Liver Disease
Pancreatitis
Stomach Cancer
Ulcers
PATIENT REGISTRATION FORMS
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Testimonials
Health History Form
Health History Form - Health History
HEALTH HISTORY FORM FOR GASTROENTEROLOGY ASSOCIATES OF NJ
Today’s Date
Patient’s Name
Age
Referred by
Previous
Next
GASTROINTESTINAL DISORDERS/SYMPTOMS
Upper GI Explain any yes answers
Changes in appetite
Yes
No
Please explain
Early satlety (feeling of fullness)
Yes
No
Please explain
Difficulty swallowing
Yes
No
Please explain
Indigestion/gas/belching
Yes
No
Please explain
Nausea/vomiting
Yes
No
Please explain
Heartburn/regurgitation
Yes
No
Please explain
Stomach pain (before or after meals)
Yes
No
Please explain
Ulcers
Yes
No
Please explain
Gallbladder disease
Yes
No
Please explain
Liver disease (jaundice,hepatitis,cirrhosis)
Yes
No
Please explain
Pancreatitis
Yes
No
Please explain
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Next
Lower GI
Abdominal pain/cramping
Yes
No
Please explain
Gas/bloating
Yes
No
Please explain
Lactose intolerance
Yes
No
Please explain
Change in bowel habits
Yes
No
Please explain
Constipation
Yes
No
Please explain
Diarrhea
Yes
No
Please explain
Rectal bleeding/hemorrhoids
Yes
No
Please explain
Mucus in stools
Yes
No
Please explain
Fecal incontinence
Yes
No
Please explain
Inflammatory bowel disease
Yes
No
Please explain
Crohn’s/ulcerative colitis
Yes
No
Please explain
Celiac Disease
Yes
No
Please explain
Irritable bowel syndrome/spastic colon
Yes
No
Please explain
Diverticulosis/diverticulitis
Yes
No
Please explain
Colon Polyps
Yes
No
Please explain
Gastrointestinal cancer
Yes
No
Please explain
Previous
Next
PREVIOUS GI TESTING (When and Where)
Blood tests
Stool tests
Abdominal x-rays or CAT scan
Upper GI series/barium swallow
Lower GI series/barium enema
Sigmoidoscopy
Colonoscopy
Upper Endoscopy
Gallbladder tests
OB HISTORY
# Full Term
#Miscarriages
#Abortions
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Next
LIST MEDICATIONS & DOSAGE:
No medications
List medications & dosage:
Do you have any allergies (including medication, food environmental, and reaction to previous blood transfusion)
Yes
No
Please describe:
Medical Conditions you have had and/or are being treated for: (i.e. heart disease, lung disease, hypertension, etc.) Continue on back if needed
SURGERIES/HOSPITALIZATIONS
Year/type
No Surgeries
No Surgeries
Have you had any problems with anesthesia?
Yes
No
PERSONAL HABITS:
Tobacco
Yes
No
pk/day
Alcohol
Yes
No
oz/day/wk
Caffeine
Yes
No
cups/day
Recreational drugs
Yes
No
year started and drugs kind
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Next
Family History:
Mother
Mother
current or past medical conditions:
Father
Age
current or past medical conditions:
Sibling M/F
Age
current or past medical conditions:
Sibling M/F
Age
current or past medical conditions:
Sibling M/F
Age
medical conditions
Sibling M/F
Age
medical conditions
Sibling M/F
Age
medical conditions
Sibling M/F
Age
medical conditions
Indicate if your parents, brothers, sisters, and/or children have a history of:
Indicate if your parents, brothers, sisters, and/or children have a history of:
Colon Polyps
Hypertension
Stomach Cancer
Pancreas Cancer
Crohn’s Stomach
Diabetes
Hearth Disease
Ulcers
Celiac Disease
Colon Cancer
Lung Disease
Kidney Disease
Ulcerative Colitis
Liver Disease
Thyroid Disorder
Signature
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Previous
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