TEANECK GASTRO RECALL QUESTIONNAIRE
Drs. Schmidt, Micale, Palance, Lin & Welinsky
Todays Date
*
-
Month
-
Day
Year
Date
PLEASE ENTER YOUR FULL NAME
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
BEST PHONE NUMBER TO REACH YOU
*
Please enter a valid phone number.
ALTERNATIVE PHONE NUMBER
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance
*
Insurance ID Number
*
2ND Insurance
2ND Insurance ID Number
Pharmacy Name
*
Pharmacy City
*
Pharmacy Phone #
*
Please enter a valid phone number.
Your Current Weight in pounds
*
Your Current Height in inches
*
Did you receive the covid vaccine?
*
yes
no
Do you take Ozempic, Wegovy, Mounjaro, Rybelsus, Trulicity, Saxenda, Byetta, Bydureon BCise, Victoza or any other GLP-1 drugs for weight loss or diabetes?
*
yes
no
How often do you take it?
*
Are you on any anticoagulants (blood thinners) like Coumadin, Warfarin, Plavix, Lovenox, Ticlid, Aggrenox, Trental, Brilante, Pradaxa, Xarelto or Effient?
*
yes
no
Name of Anticoagulant Drug
*
Dose
*
Frequency taken
*
If yes, who prescribed it? (name and phone number)
*
Do you have any blood clotting disorders? (bleeding or clotting issues)
Yes
No
Do you take aspirin on a daily basis?
*
yes
no
If yes, which strength do you take?
*
81 mg (baby aspirin)
325 mg
If yes, who prescribed it? (name and phone number)
*
Are you diabetic?
*
yes
no
If yes, what diabetic medications do you take? (name)
*
diabetic medication dose
*
frequency that you take diabetic medications (once a day, twice a day, etc.)
*
2nd diabetic medications (name)
*
2nd diabetic medication dose
*
frequency that you take diabetic medications (once a day, twice a day, etc.)
*
Do you take your diabetic medications in the
*
morning
evening
Do you take a diuretic or water pill?
*
yes
no
If yes, what is the name of the water pill?
*
Dose of Water Pill
*
Frequency taken (once a day, twice a day)
*
What time of day do you take your water pill?
*
morning
evening
Do you take blood pressure or cardiac medications?
*
YES
NO
If yes, what blood pressure or cardiac medication do you take (name and strength)?
*
Dose of Blood pressure medication
*
Frequency that you take Blood pressure medications (once a day, twice a day)
*
what time of day do you take your blood pressure medication?
*
morning
evening
Who prescribed this medication? Please include name and phone number.
*
Do you take iron pills or vitamins that contain iron?
*
yes
no
Do you take antibiotics before going to a dentist?
*
yes
no
What antibiotic do you take (name, dose and frequency)
*
Are you allergic to any antibiotics?
*
yes
no
If yes, what antibiotic are you allergic to?
*
Have you been on antibiotics in the last month?
*
yes
no
If yes, for what condition did you take antibiotics?
*
What antibiotic were you taking?
*
Do you have any STENTS or have you had cardiac bypass surgery?
*
yes
no
Have you had rheumatic fever or heart valve replacement?
*
yes
no
Do you have congestive heart failure?
*
yes
no
Do you have an implantable defibrillator?
*
yes
no
Do you have a pacemaker?
*
yes
no
Have you had an echocardiogram, stress test, nuclear stress test, cardiac catheterization or holter monitor in the last 5 - 10 years?
*
yes
no
If so, When
Why?
Do you see a cardiologist?
*
yes
no
If you do see a cardiologist, Why?
Have you had a hip, knee or joint replacement in the last six months?
*
yes
no
Are you a renal dialysis patient?
*
yes
no
Do you have a history of hepatitis or cirrhosis?
*
yes
no
Do you have lung disease, asthma, COPD (chronic obstructive pulmonary disease) or sleep apnea?
*
yes
no
Do you use supplemental oxygen?
*
yes
no
Are you over the age of 75?
*
yes
no
Since your last procedure, have you had a heart attack or stroke?
*
yes
no
Have you ever had a hard time cleaning out for your colonoscopy?
*
yes
no
Do you have ulcerative colitis or Crohn's Disease?
*
yes
no
Patient Signature
*
Preview PDF
Submit
Should be Empty: