Integrated Physicians Group, LLC
Breast, Colo-Rectal, & General Surgery
Ravindra Kandula. M.D., Chand Rohatgi, M.D., Anthony Dippolito, M.D., Jadd Koury, M.D.
2649 Schoenersville Rd. Suite # 203 Bethlehem, PA 18017 Phone: (610) 861-0470 Fax: (610) 861-0208
3735 Nazareth Rd. Suite # 103 Easton, PA18045 Phone: (610) 252-1999 Fax: (610) 252-0573
201 Drift Court Bethlehem, PA 18020 Phone: (610) 882-9111 Fax: (610) 882-9946
Date: _____/______/_______ Time: _________ am / pm
Name: ________________________________ Gender: M /F
D.O.B: ______/______/______ SS#: __________________Marital Status: M/S/W/D
Address: _______________________________________________ City____________________________ State: _______ Zip: _________
Phone: _________________________ Cell: __________________________Work:_________________________ ext. #_______________
PCP: ________________________ Gyn: _____________________Other (s):__________________________Referred by: _____________
Age: ____ Height: ______ Weight: ______ Race: _____________ Occupation: __________________ Email________________________
Primary Insurance: _______________________________ Policy #: ______________________________ Group #: __________________
Subscriber______________________________________ D.O.B.: ______________________ S.S. #: ______________________________
What is the reason for your visit today? _________________________________________________________________
What has been done for the problem so far? _____________________________________________________________
Current or Past Medical History
Liver Failure
Kidney Failure
Hepatitis or HIV (AIDS)
Thryoid or Adrenal Condition
Stroke, TIA, or Mini Strokes
Excessive Bleeding, Trouble Clotting, Easy Bruising
Cancer
Other Diseases (Communicable, TB)
Diabetes
Sleep Apnea
MRSA
Comments:
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
/
/
/
/
/
/
/
/
/
/
/
N
N
N
N
N
N
N
N
N
N
N
Lifestyle / Social
Smoking
Alcohol
Drugs (Including pain and street drugs)
Comments:
Y / N
Y / N
Y / N
Neuropsychological
Seizures or Convulsions
Dizziness, Fainting, Fatigue, Weakness
Y / N
Y / N
_____________________________________
_____________________________________
Comments:
Y
Y
Y
Y
Y
Y
Y
Y
/
/
/
/
/
/
/
/
N
N
N
N
N
N
N
N
Respiratory
Asthma or Chronic Lung Disease
Cough / Wheezing
Pneumonia
Bronchitis
Difficulty breathing when lying down
# Daily______________ # of Years________
# Daily______________ # Weekly_________
Type________________ # of Years________
Comments:
Cardiovascular
Heart Disease
Heart Attack (MI) Or Congestive Heart Failure
Heart Surgery, Angioplasty, Stents, Catheterizations
Pacemaker of Defibrillator
High Blood Pressure
Low Blood Pressure
High Cholesterol
Low Cholesterol
_____________________________________
Dialysis Needed: Yes / No
_____________________________________
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CPAP Required: Yes / No
_____________________________________
_____________________________________
Date: ________________________________
Date: ________________________________
Date Implanted:__________ Brand:________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Comments:
Y
Y
Y
Y
Y
/
/
/
/
/
N
N
N
N
N
_____________________________________
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_____________________________________
_____________________________________
_____________________________________
Date of Visit
Patient Initials
Physician Initials
Page 1 of 2
Patient Name_________________________________________
D.O.B.________/_______/__________
Gastrointestinal
Nausea
Diarrhea
Constipation
Abdominal Pain
Gas / Belching
Indigestion
Hiatel Hernia, Reflux, or Stomach Ulcers
Comments:
Y
Y
Y
Y
Y
Y
Y
/
/
/
/
/
/
/
N
N
N
N
N
N
N
Female Use Only
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
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Comments:
Any Possibility of Pregnancy
Y / N
Age of first Menstrual Period________________
Last Normal Menstrual Period_____________Number of pregnancies________ Live Births_______ Abortions_____ Miscarriages_______
Do you or did you breast feed?
Y / N
_____________________________________
Do you perform regular breast self exams
Y / N
_____________________________________
Breast Pain
Y / N
When__ __________ For how long______________
Nipple Discharge
Y / N
Color______________ For how long___________
Breast Abscess; Infections
Y / N
_____________________________________
Have you ever taken birth control hormones (i.e. pill, patch, injection)Y / N
_____________________________________
Are you currently taking birth control hormones
Y / N
Type_________________________________
In total, how many years have you taken birth control hormones ______
_____________________________________
Have you ever taken medication to assist in getting pregnant?
Y / N
Type_______________How many _________
Have you ever taken Hormone Replacement Therapy?
Y / N
_____________________________________
If so, how long were you taking HRT?
_____________________________________
Have you ever taken Tamoxifen
Y / N
For How Many Years___________________
If yes, please circle one: For Treament of cancer or DCIS or For Prevention of cancer.
Please list all previous surgical procedures (invasive and non-invasive)
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Please list all Medications and Herbal Supplements both prescribed and/or over the counter that you take
Medication Dosage Frequency Reason for taking
Medication Dosage Frequency Reason for taking
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
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Please list ALL medications, metals, dyes, latex, or food allergies and the reaction.
______________________________________________________________________________________________
Additional Medical History
______________________________________________________________________________________________
______________________________________________________________________________________________
Do you have any dental or oral appliances, loose or capped teeth or body piercings?
Y/N
Have you or any relatives ever had serious problems with anesthesia? Y / N
Do you have any special needs (cultural, physical, religious, medical, emotional, communication barrier)? Y / N
Have you had any recent blood work or EKG done within the last 30 days? Y / N
Location: _________________________
Date of Visit
Patient Initials
Physician Initials
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