New Patient Information Packet
Please:
1) Review “Payment Terms and Agreements”, “Notices of Privacy Practices for
Protected Health Information” and “Online Communications Policy” located on this
website
2) Print the 2nd and 3rd pages of this packet to fill out
3) Sign the following Consent/Signature sheet and the New Patient History form
4) Arrive 10 minutes prior to your scheduled appointment
5) Call at least 24 hours in advance if you need to cancel or reschedule
6) Be sure to bring both the Consent/Signature sheet and New Patient History form
with you to your appointment.
7) You will also need to bring your insurance card, any applicable co-pay and a photo
ID.
Summit Gastroenterology
Barcode
Patient Consent, Contact and Signature sheet
PLEASE PRINT:
Patient Name: ___________________________________________ Date of Birth: _____________________
Social Security #: _________________________________
Present Address: _________________________________________________ Apartment #: _________
City ______________________
State ____________
Zip ___________________
Telephone (#1) ________________________ This is how we will contact you to provide results and appointment reminders
(#2) ________________________ This is our backup number to reach you
Primary Language______________________
Race ______________________
Ethnicity ____________________
………………………………………………………………………………………………………………………
In case of emergency please notify:
Emergency contact name ____________________________________ Relation _______________________
Telephone _____________________________
………………………………………………………………………………………………………………………
*PLEASE PROVIDE YOUR INSURANCE CARD AND PHOTO ID TO THE RECEPTIONIST
NAME OF PRIMARY INSURED (if different from above) _______________________________________________
SS# OF PRIMARY HOLDER (if different) ___________________DOB OF PRIMARY HOLDER ______________
RELATIONSHIP TO PATIENT ____________________________
………………………………………………………………………………………………………………………
(Please review the Patient Information Packet before signing below. Please note that we will leave normal lab
or test results on your answering machine unless you specifically ask us not to)
1) I have reviewed the document, “PAYMENT TERMS AND AGREEMENTS, V 2/11/2011” and my
signature here indicates that I agree to the terms set forth: X__________________________________
Signature of patient or patient representative
2) I have reviewed the document, “Notice of Privacy Practices for Protected Health Information”:
X__________________________________
Signature of patient or patient representative
3) I authorize the exchange of pharmacy information between my pharmacy and Dr. Aaron Burrows, MD P.C.:
X__________________________________
Signature of patient or patient representative
4) I have reviewed the “Online Communications Informed Consent” and “Patient Portal Info”:
X__________________________________
Signature of patient or patient representative
My email address is: __________________________________ (This allows us to notify you of test results and
allows you access to the patient portal.)
CONFIDENTIAL PATIENT INFORMATION
Your Name:
Your Age:
Your Referring Doctor:
Patient barcode goes here
(do not write in this section)
What is your Chief Complaint?
Regarding this illness, do you have or have you had:  Abdominal pain  Heartburn/reflux  Nausea  Vomiting
Blood in vomit
Difficulty swallowing  Loss of Appetite Constipation
 Diarrhea  Fever
Red
Blood in stool  Black/tarry stools  Unintended weight loss  Regurgitation of food  Yellow skin/eyes
Have you ever had a COLONOSCOPY: Yes -when?____________
No
Have you ever had an Upper Endoscopy (EGD) : Yes- when?___________ No
Please list your past medical history:
Please list all your previous surgeries (and approximate dates):
Please list all your current medications. Include birth control, aspirin, over-the-counter, or homeopathic medicines:
Drug allergies and type of reaction:
Which Vaccinations have you had?:  □Hepatitis A-Year completed:
 □Hepatitis B-Year completed:
Family Health (please list any health problems or cancers for your immediate family):
Mother:
Father:
Siblings:
Grandparents:
Is there a history of colon polyps in your family?  Yes  No  I don’t know
Smoking? Yes  No  Former
Recreational Drugs? Yes  No Type:_________
How many years did you smoke? :______ How Much?: ______
Alcohol? None Occasional Moderate
Heavy
Caffeine use:  None  Moderate  Heavy
Occupation:
Diet: Regular  Vegetarian
Sexual History: Sexually active?  Yes  No  Heterosexual  Homosexual  Bisexual
Your Height: ___________
Weight: _______________
Review of Systems (Please circle only those conditions below that you have or have had in the past)
Constitutional:  Fatigue
 Fever
 Night sweats
 Weight gain
(________lbs)
 Weight loss (________ lbs)
 Hearing loss  Nose bleeds  Sinus Problems  Sore throat  Bleeding gums  Snoring  Mouth ulcers
Cardiac:  Chest Pain/Pressure Arm pain on exertion
 Shortness of breath
 Palpitations
Heart Murmur  Angina /Heart Attack  Heart valve infection  CHF  Leg Edema  Abnormal EKG
Respiratory:  Cough
COPD/Emphysema
 Wheezing
 Shortness of breath  Asthma


ABNORMAL
Digestive:  Abdominal pain  Vomiting
ABNORMAL
 Change of Appetite  Black or tarry stools
Celiac Sprue/Gluten sens
Lactose Intolerance
Hepatitis C
Hemorrhoids
Diverticulosis
Hiatal Hernia
Ulcers
 Pancreas problems
Liver disease
Gallbladder problems
Inflammatory
Bowel Disease
 Irritable Bowel Syndrome  GI Cancers:_________
 Sensitivities to foods
_________________ 
Infection
Fatty Liver
Reflux/GERD

Colitis
Urinary:  Urinary loss of control
 Incomplete emptying 
 Difficulty urinating
 Urinary frequency
Kidney Stones  Urinary Infections  Chronic Kidney
Disease
Muscles/Bones:  Muscle aches/weakness
Osteoporosis
Neuro:
Loss of consciousness Weakness
 Joint pain
 Back pain
Numbness

Seizures
 Dizziness
Psychiatric:  Depression
Schizophrenia
Headaches
Stroke
 Anxiety

 Hair falling out
 Chronically tired  Thyroid Disease
Reproductive Problems  Diabetes
Multiple Sclerosis
 Sleep disturbances
Mania
 Feeling unsafe in a relationship
Anorexia
Bulemia
Endocrinology:  Increased thirst

Alcohol abuse
 Increased hair growth
Pituitary Problems  Adrenal Problems 
Hematology:  Swollen glands
 Bruising
 Bleeding problems  Anemia (low
red blood cell count)
 Low platelets  High/low white blood cells  Blood Cancers
 HIV+  Blood
transfusions  STD
Skin/Allergy:
Skin rashes
 Jaundice  Eczema  Bruising
Itching
Hives
Sneezing