Summit Gastroenterology
4500 East 9th Avenue
Suite 530-S
Denver, CO, 80220
(303) 320-1111
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 5-10 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
Summit Gastroenterology
Patient Consent, Contact and Signature sheet
CONFIDENTIAL PATIENT INFORMATION
Because of electronic billing, if all information is not complete, we are unable to bill.
PLEASE PRINT:
Patient Name: ___________________________________________ Date of Birth: _____________________
Social Security #: _________________________________ (To limit identity theft, this SS# is used for
identification purposes only if necessary and is not stored electronically in your medical record in order to limit
potential unauthorized viewing. This page is the only location that your social security number is stored).
Present Address: _________________________________________________
City ______________________
State ____________
Apartment #: _________
Zip ___________________
Telephone (home) __________________________
(work/cell) _______________________
………………………………………………………………………………………………………………………
In case of emergency please notify:
Emergency contact name ____________________________________ Relationship ______________________
Telephone _____________________________
………………………………………………………………………………………………………………………
*PLEASE PROVIDE YOUR INSURANCE CARD AND PHOTO ID TO THE RECEPTIONIST
NAME OF PRIMARY INSURED ________________________________________________
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 and recommendations on your answering machine unless you specifically ask us not to)
You must sign the first two lines in order to receive care today
1) I have reviewed the document, “PAYMENT TERMS AND AGREEMENTS, V1.2 8/11/08” 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 had the opportunity to review “Online Communications Informed Consent”:
X__________________________________
Signature of patient or patient representative
My personal email address is: (optional) __________________________________ (note: you must provide an
email address if you wish to receive educational mailings and receive invitations to educational lectures, in
addition to communicating with Dr. Burrows via email). If you do not have an email account, you may still
communicate with Dr. Burrows via telephone.
Please complete this NEW PATIENT HISTORY prior to your initial visit
Your Name:
Your Age:
What is your chief complaint today? :
Your Referring Doctor is:
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:
Would you be interested in being vaccinated for either of these today?  Yes  No
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 How much?
Occupation:
Sexual History:
Alcohol? Yes  No  Former
Caffeine use:  None  Moderate  Heavy
Sexually active?
Recreational Drugs? Yes  No
Diet:
 Regular  Vegetarian
 Yes  No  Heterosexual  Homosexual  Bisexual
Review of Systems (Please check only those conditions below that you have or have had in the past)
Head: Visual problems:____________ Hearing problems:________________ Throat problems:_________________
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 on exertion
 Palpitations
 Heart Murmur  Angina /Heart Attack
 Heart valve infection  CHF  Leg Edema  Abnormal EKG
Respiratory:  Cough
 Wheezing  Shortness of breath  Asthma
 COPD/Emphysema
Digestive:  Abdominal pain  Vomiting  Change of Appetite  Black or tarry stools  Diarrhea
 Celiac Sprue/Gluten sens
 Lactose Intolerance
 Hepatitis C
 Hemorrhoids
 Diverticulosis
 Hiatal Hernia
 Stomach Ulcers
 Pancreas problems
 Liver disease
 Gallbladder problems
 Inflammatory Bowel Disease
 Irritable Bowel Syndrome  GI Cancers:_________
 Sensitivities to foods _________________
 H. Pylori Infection
 Fatty Liver
Reflux/GERD
 Colitis
Urinary:  Urinary loss of control  Difficulty urinating  Blood or pus in urine  Urinary frequency
 Incomplete emptying  Kidney Stones  Urinary Infections  Protein in urine  Chronic Kidney Disease
Muscles/Bones:  Muscle aches  Muscle weakness  Muscle/Joint pain  Back pain  Osteoporosis
Skin:
 Skin rashes
 Itching
 Jaundice  Eczema  Bruising  Seizures
Neuro:
 Loss of consciousness Weakness
 Numbness
 Seizures  Dizziness
 Headaches
 Stroke
 Multiple Sclerosis
Psychiatric:  Depression  Mania  Sleep disturbances  Feeling unsafe in a relationship  Alcohol abuse
 Anxiety  Schizophrenia
 Eating Disorders
 Dementia
Endocrinology:  Increased thirst  Hair falling out  Increased hair growth  Chronically tired  Diabetes
 Thyroid Disease  Pituitary Problems  Adrenal Problems  Reproductive 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
Allergy:
 Runny nose
 Itching  Hives
 Sneezing