ASSOCIATES IN GASTROENTEROLOGY, P.A.
SIVA K. CHOCKALINGAM, M.D.
PATIENT INFORMATION
Date: _________________ Primary Care Doctor: ______________________ Referring Doctor: _________________________
Patient:
___________________________________________________________________________________
Patient’s Legal Guardian’s Name: (if minor) _____________________________________________________________________
Address: __________________________________________________________________________________
City:
________________________________ State: ________________ Zip Code: ________________________
Home No._________________
Cell No._____________________ Work No.__________________________
Can we E-mail you? If so what is your email address: _______________________@_______________.com
«DOB»
Social Security No. ___________________ Refuse to provide
Marital Status: (please circle):
Married
Race: Circle One:
African American
Asian
Widowed
Divorced
Single
Caucasian
Native Hawaiian or Other Pacific Islander
Sex (please circle):
Male
Female
Hispanic
American Indian or Alaska Native
Unknown
Patient declines to specify
Employer: _________________________________________________City: ____________________________________________
Work Phone No. ____________________________ Occupation: ___________________________________________________
Your Employment Status: (please circle)
Are you in Hospice? _____Yes
Active
Retired
Disabled
Unemployed
_____No
Emergency Contact (Not currently living with you): _______________________________________ Phone: ____________________
Relationship to Patient: _______________________________________________________________________________________
Spouse’s Name: _____________________________________________________________________________________________
Spouse’s Social Security No. ____________________________________ Date of Birth: __________________________________
Spouse’s Employer: __________________________________________________________________________________________
Employer’s Address: _________________________________________________________________________________________
Work Phone No. ______________________________Occupation: ___________________________________________________
Spouse’s Employment Status: (please circle)
Active
Retired
Disabled
Unemployed
Pharmacy Name: __________________________City:_______________________ Pharmacy Phone: ______________________
PRIMARY INSURANCE: __________________________________________________________________
Contract/I.D. No. ________________________________________ Group No. /Name: ___________________
Policyholder Name: ______________________________________ Relationship: _______________________
SECONDARY INSURANCE: _______________________________________________________________
Contract/I.D. No. _______________________________________ Group No. /Name: ____________________
Policyholder Name: _____________________________________ Relationship: ________________________
ASSOCIATES IN GASTROENTEROLOGY, P.A.
SIVA K. CHOCKALINGAM, M.D.
Patient Name: _________________________________________
Date: ________________
Reason for Today’s Visit: _______________________________________________________
MEDICAL HISTORY:
(Please check the box next to any condition you had or have)
Acid Reflux
Alzheimer disease
Alcoholism
Atrial fibrillation
Anxiety
Anemia
Asthma
Barrett’s Esophagus
Bipolar Disorder
Diverticulosis
Diverticulitis
Non-Insulin Diabetes
Insulin Diabetes
Endometriosis
Fibromyalgia
Gallstones
Gastric Ulcer
Gastritis
Irritable bowel syndrome
Osteoarthritis
Osteoporosis
Pancreatitis
Parkinson’s Disease
Pulmonary embolism
Peptic stricture
Peptic ulcer
Renal failure
Bleeding Problems
Coronary Artery Disease
Cancer Location:
Cirrhosis
Colon polyps
Colon cancer
COPD/Emphysema
Crohn’s Disease
Depression
Deep vein thrombosis-clot
Glaucoma
H. pylori
HIV
Heart Attack / Angina
Hepatitis B
Hepatitis C
High cholesterol
High Blood Pressure
Hyperthyroidism
Hypothyroidism
Rheumatoid arthritis
Rheumatic fever
Seizures /Epilepsy
Sickle Cell Anemia
Sleep apnea
Spine Disease
Stroke
Ulcerative Colitis
Other diseases:
Other Diseases:
SURGICAL HISTORY: ( ) NONE
Abdominal aortic aneurysm
Appendix-Appendectomy
Bladder suspension
Bowel obstruction
Breast biopsy
Breast removal
Carotid artery
Carpal tunnel
Colonoscopy
(Please check the box next to any surgery you had)
Heart catheterization
with balloon angioplasty
with stent placement
Heart pacemaker
with defibrillator
Heart Valve Replacement
Hemorrhoidectomy
Hiatal hernia repair
Hip replacement
Left or Right or Both
Total Hysterectomy
Open Heart Surgery
Peptic ulcer surgery
Prostate surgery
Prostate radiation seeds
Removal of ovaries
Skin cancer removal
Tonsillectomy
Tubal ligation
Vascular Surgery
Where:______________
Other:
Partial Hysterectomy
Inguinal hernia repair
Other:
Endoscopy
Diverticulosis resection
Gallbladder, laparoscopic
(Cholecystectomy)
Gallbladder, open
Gastric By-Pass
Other:
Knee replacement
Left or right or Both
Liver biopsy
Lung resection
Other:
Colon resection
Caesarean
Other:
Other:
Other:
ASSOCIATES IN GASTROENTEROLOGY, P.A.
SIVA K. CHOCKALINGAM, M.D.
IMMUNIZATION: ( ) NONE
HAS ANYONE IN YOR FAMILY HAD: ( ) NONE
When:
Relationship:
Hepatitis A
Hepatitis B
Influenza
Pneumonia
HPV
PPD
Autoimmune Disease
Bleeding/Clotting
Celiac Disease
Crohn’s Disease
Colon Cancer
Colon Polyps
Gallstones
Liver Disease
Pancreatic Cancer
Stomach Cancer
Ulcerative Colitis
SOCIAL HISTORY: (Please check the box)
Number
of Children: ___________
Check mark
Check mark
Exercise :
Tobacco:
None
Never Smoked
Type:________
How
often:_______
Current Everyday Smoker
Alcohol:
Former smoker
None
Drugs:
Beer
None
Wine
Marijuana
Liquor
Heroine
How often?
______
How many?
______
Cocaine
Current Some day smoker
LSD
Crack
How
often:__________________________
ASSOCIATES IN GASTROENTEROLOGY, P.A.
SIVA K. CHOCKALINGAM, M.D.
Patient Name: ________________________________________
REVIEW OF SYSTEMS—(Circle Yes or NO)
Constitutional None
Tired / Fatigued
Confusion
Sweats
Loss of Appetite
Fever
Weight loss
Eyes None
Blurred vision
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Musculoskeletal
Muscle aches
Knee pain
Sciatica
Swollen joints
SKIN - None
Easy bruising
Hives
Itching
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Cataracts
Itchy and redness
Yes
Yes
No
No
Rashes
Neurological -None
Yes
Yes
No
No
Discharge
Yes
No
Difficulty speaking
Yes
No
Yes
Yes
No
No
Loss of strength
Loss of use extremities
Yes
Yes
No
No
Dry mouth
Sinus trouble
Respiratory
Cough
Shortness of breath at rest
wheezing
Cardiovascular None
Chest Pain at rest
Shortness of Breath when resting
Irregular heart beat
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
Seizures
Tingling
Numbness
Psychiatric None
Anxiety
Depression
Substance Abuse
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Yes
No
Dizziness
Fainting
Palpitations
Gastrointestinal None
Abdominal pain
Abdominal swelling
Change in bowels habits
Constipation
Diarrhea
Swallowing problems
Gas
Heartburn
Jaundice
Nausea
Vomiting
Yes
Hemorrhoids
Rectal pain
Heartburn
Genitourinary None
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Blood in urine
Difficulty urine flow
Painful urination
Yes
Yes
Yes
No
No
No
ENMT Decreased hearing
None
No
Suicidal Thoughts
ASSOCIATES IN GASTROENTEROLOGY, P.A.
SIVA K. CHOCKALINGAM, M.D.
Dear Patient,
On behalf of all the staff, I welcome you to our office. We are pleased that you have selected us to care for your healthcare
needs. We want you to know that we are committed to providing you with courteous, compassion and education you on your
condition while respecting your privacy.
During your first visit we will conduct a thorough examination. The exam will included a discussion of your medical history
and the reason you are visiting us. Your doctor will them discuss his diagnosis and the suggested treatment with you. This visit is a
consultation; a procedure will not be done on your first visit with us.
Enclosed you will find a New Patient Packet, which includes the following documents,
1. Patient Demographics Information
2. A History and Physical Questionnaire
3. A Medication List
4. Office Policies and Patient Responsibilities
5. Notice of Privacy Practices
6. Acknowledgement Form for the Notice of Privacy Practices
7. Authorization to Release Information Form: to give permissions for telephone messages, work excuses, school excuses,
and an option for you to give specific permission to any family member or friend you wish to designate to participate in
your healthcare with our office.
8. Directions to our offices
Please read and complete the packet in its entirety and bring it with you to your appointment. Also, do not forget to bring
your insurance card and picture id, and any medical records that pertain to the reason of your visit. On the day of your visit, please
come prepared to pay a co-insurance, co-pay or deductible that may apply to this office visit. A pre-authorization or referral may be
required due to your insurance requirements. If possible, please arrive 15 minutes early so we can go over your information and any
questions you may have.
Should you any questions before your visit, please feel free call us. We look forward to seeing you on your schedule
appointment. If you cannot make the appointment that has been scheduled for you, please contact our office at least 48 hours
before your scheduled appointment time to reschedule or cancel.
Sincerely,
Siva K. Chockalingam, M.D.
ASSOCIATES IN GASTROENTEROLOGY, P.A.
SIVA K. CHOCKALINGAM, M.D.
Directions to Columbia office from:
1. N.E. Columbia: Go toward I-20 on Clemson Rd., take a right onto Wildewood Centre Drive at the Shell Gas
Station/Dunkin Donuts.
We are the last building on the right hand side of the road:
1070 and 1072 Wildewood Centre Drive
2. N.W. Columbia: Take I-20 toward Florence, get off on Exit 80 Clemson Rd. Take a left on Clemson Rd., at the first
traffic light, then take a left onto Wildewood Centre Drive at the Shell Gas Station/Dunkin Donuts.
We are the last building on the right hand side of the road:
1070 and 1072 Wildewood Centre Drive.
3. Camden: Take I-20 W towards Columbia, take Exit 80 to Clemson Rd., and turn right onto Clemson Rd. get into the far
left hand lane at the traffic light turn left at the Shell Gas Station/Dunkin Donuts on to Wildewood Centre Drive.
We are the last building on the right hand side of the road:
1070and 1072 Wildewood Centre Drive
4. Sumter: Take 378 to 601 North. Take a left onto Screaming Eagle Rd. into Pontiac. Then take I-20 W towards
Columbia, take Exit 80 to Clemson Rd. turn right onto Clemson Rd. get into the far left hand hand lane, then turn left at
the Shell Gas Station/Dunkin Donuts on to Wildewood Centre Drive.
We are the last building on the right hand side of the road:
1070 and 1072 Wildewood Centre Drive
Sumter: Take 521 to Camden, get on I-20 W towards Columbia. Take Exit 80 to Clemson Rd. Turn right onto Clemson Rd.
get into the far left hand lane and turn left at the Shell Gas Station/Dunkin Donuts on to Wildewood Centre Drive.
We are the last building on the right hand side of the road at:
1070 and 1072 Wildewood Centre Drive
5. Lexington: Take I-20 E towards Florence, take Exit 80 to Clemson Rd., turn left onto Clemson Rd. at the first traffic
light, and turn left at the Shell Gas Station/Dunkin Donuts on to Wildewood Centre Drive.
We are the last building on the right hand side of the road at:
1070 and 1072 Wildewood Centre Drive
1070 and 1072 Wildewood Centre Drive • Columbia, SC 29229 • Phone: (803) 788-1100 • Fax: (803) 788-4522