Old Ocean City Blvd, Suite 1 Berlin, md 21811 Patient Information

Patient Name ______________________________ Today’s Date ______________________________

Home Address _____________________________ Work Phone #______________________________

__________________________________________ Cell Phone # ______________________________

Mailing Address ____________________________ Patient’s Sex Male ___ Female ___

__________________________________________ Date of Birth ______________________________

Primary Physician ___________________________ Employer _________________________________

Referring Physician __________________________ Employer’s Address _________________________

Occupation ___________________________

Name of Insurance Company ___________________ E-mail address _____________________________

Name of Policy Holder ________________________ Marital Status: Single Married Divorced Widowed

Patient’s Relationship to Policy Holder ___________

Policy Holder’s Date of Birth ___________________

Native Hawaiian Arabic

Other Pacific Islander Chinese

Black/African American Chinese (Cantonese)

American Indian/Alaska Native Chinese (Mandarin)

White English

More than 1 race Filipino

Unreported/Refused to report French

Greek

Ethnicity Italian

Hispanic/Latino Japanese

Not Hispanic/Latino Korean

Unreported/Refused to report Other ______________________

Spanish

Vietnamese

I hereby authorize Dr. Canakis and his staff to speak to the following people regarding my healthcare. The first person listed is my emergency contact.

Name:________________________________ Relationship:______________________________

Name:________________________________ Relationship:______________________________
Signature:__________________________________________ Date:_________________________________
Revised 11/6/14

Jerrold S. Canakis, M.D., P.A.

Gastroenterology

10344 Old Ocean City Blvd, Suite 1 Office: 410-641-2938

Berlin, MD 21811 Fax: 410-641-4904
Patient Consents

HIPAA POLICY: I have been given access to, and have read, the HIPAA policy for Dr. Canakis’ practice.
Signature: ________________________________________ Date:________________________________


Assignment of Benefits: I hereby authorize my insurance company(s) to make payment(s) as stipulated in my policy for any services furnished and that such payment(s) be paid directly to the provider of the service. I also understand that I am financially responsible for all services provided and agree to pay upon demand or as agreed for the related charges or remaining charges following my insurance payment(s).
I understand all co-pays will be collected at the time of service. All prior balances must be reconciled either by mail prior to, or at, my next visit, whichever is sooner. The office accepts cash, check, VISA and MasterCard. A $25.00 returned check fee will be applied to my account for all returned checks.
The undersigned acknowledges that if his/her account becomes delinquent (over 120 days past due) and is referred to our attorney for collection, then in such event, the undersigned agrees to pay an additional 33.33% of the outstanding balance, which represents reasonable attorney fees for the collection of the account, and in addition, agrees, acknowledges and understands that the undersigned will be responsible to pay all court costs expended in an effort to collect the delinquent account. In addition, if any suit must be filed to collect an unpaid balance on an account, patient, and/or guarantor, agrees that such suit may be brought in courts of Worcester County, Maryland, and waives any objection to jurisdiction or venue.
I understand I may be charged a fee if I miss my appointment or do not cancel at least 24 hours prior to my appointment. This fee is not covered by my insurance carrier and must be paid prior to my next appointment.
Signature: ________________________________________ Date:__________________________________

Allscripts Medical Community Consent:

I hereby authorize Dr. Canakis and his staff to access my medical records electronically from Atlantic General Hospital and my other physicians when appropriate and available.

Revised 11/6/14

Name:_______________________________________ Date of Birth:______________________________

Have you had any labs/radiology tests regarding this problem? If so, what and where?___________________

_________________________________________________________________________________________

Who referred you today:_____________________________________________________________________

Local Pharmacy ___________________________________Mail Order Pharmacy_______________________
Medications (Prescription and over the counter vitamins and supplements):

Name Reason you take it Name Reason you take it

_____________________________________ _________________________________________

_____________________________________ _________________________________________

_____________________________________ _________________________________________

_____________________________________ _________________________________________

Please use back of form if needed.
Medication Allergies:

Name Reaction_________ __ Name Reaction_________

______________________________________ _________________________________________

______________________________________ _________________________________________
Surgical History (Please list your surgeries and approximate year performed):

______________________________________ _________________________________________

______________________________________ _________________________________________

______________________________________ _________________________________________

Colon cancer……..No/Yes….Who_____________ Liver cancer……..No/Yes……Who_______________

Colon polyps………No/Yes…..Who_____________ Crohn disease…..No/Yes……Who_______________

Celiac disease…….No/Yes…..Who_____________ Colitis……………….No/Yes……Who_______________

Pancreatic cancer…No/Yes……Who____________ Stomach cancer…..No/Yes….Who_______________

Esophageal cancer/Barrett esophagus……..No/Yes……Who________________

Marital status: Single Married Separated Divorced Widow/Widower

Occupation: Currently employed N/Y Employer__________________________________________________

Student Retired Unemployed

Tobacco: Never smoker Current smoker #PPD ______ #YRS______ Previous smoker Quit _________

Alcohol: None Socially Daily # per day _______ Recovering alcoholic

Illicit drug use: Never used Currently use Previously used

Have you ever had a colonoscopy? _______ When?________ Findings _______________________________

Have you ever had an upper endoscopy? ________ When? ________Findings _________________________­­_

Do you have an AICD (an implanted defibrillator)? _________

What medical providers would you like your notes to be sent to?_____________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

___________________________________________________________________________rev 6-20/14

Feeling well Bruising Headache Hoarseness

Appetite loss Dryness Blurred vision Oral ulcers

Fatigue Itching Hearing loss Sore throat

Fever New lesions Nosebleeds Choking sensation

Night sweats Rash Cold Difficulty chewing

Weight gain Skin color changes Seasonal allergies Yellowing of eyes

Weight loss Sleep apnea

Pain Abdominal pain Back pain Dizziness

Stiffness Belching Calf pain Numbness

Swollen glands Black, tarry stool Joint pain Weakness

Bloating Muscle cramps

Respiratory Bloody stool

Cough Change in bowel habits Psychiatric Endocrine

Difficulty breathing Constipation Anxiety Cold intolerance

Coughing up blood Diarrhea Depression Excessive thirst

Snoring Difficulty swallowing Change in sleep pattern Excessive urination

Wheezing Heartburn Mood Changes Heat intolerance

Jaundice

Cardiovascular Nausea

Chest pain Painful swallowing Hematology

Shortness of breath Rectal bleeding Easy bruising

Swelling of extremities Vomiting Easy bleeding

Vomiting blood Enlarged lymph nodes

Prolonged bleeding

_________________________________________________________________________

Have you had surgery since your last visit? ______. When?_____. Where? ______.

Have you been to the ER since your last visit? _____. When?______. Where?______.