Spouse's Date of Birth

Please Check

Primary Insurance Company

Full Name of Card Holder

Card Holder's Date of Birth

Card Holder's Social Security #

Card Holder's Social Security # (copy)

Patient's Relationship to Card Holder

Is this Plan:

Medicaid

Disability

Cobra

Workman's Comp.

Reason for your appointment today

Approximate date your symptoms appeared

Please List all previous surgeries and their corresponding dates

Are you aware of any problems with anesthesia? YES or NO? (If your answer is yes, please explain below)

Are you aware of any problems with insertion of a breathing tube for surgery?

Yes

Have you taken any steroids within the last six (6) months?

Yes

Please list all known allergies and your corresponding reactions

Are you allergic to Latex?

Yes

Are you allergic to Surgical Tape?

Yes

I have NO medication allergies

Please list all current medications/vitamins. Include dosage, frequency, and reason

Medical Condition Relationship

Diabetes Mellitus
High Blood Pressure
High Cholesterol
Obesity
Stroke
Heart disease
Depression
Alcoholism
Thyroid Disorder
Cancer
Blood Disorder
Kidney Disease
Lung Disease
Other

Do you currently smoke?

Yes

If so...are you willing to quit?

Yes

Do you drink alcohol?

Yes, Daily

Yes, Weekly

Yes, Monthly

Do you use recreational drugs?

Yes, Daily

Yes, Weekly

Yes, Monthly

Do you exercise?

Yes, Daily

Yes, Weekly

Yes, Monthly

What type of exercise do you do?

Have you been diagnosed with any of the following? Please check all that apply

SIGNING THIS AUTHORIZATION MEANS YOU AUTHORIZE THE RELEASE OF INFORMATION INCLUDING THE DIAGNOSIS, RECORDS, AND EXAMINATION RENDERED TO ME AND DR. ELIAS DARIDO, HOUSTON HEARTBURN & REFLUX CENTER.

2100 WEST LOOP SOUTH, SUITE 1115, HOUSTON, TX 77027 Fax : 281.762.1452.

If you have any questions please call our office at (832) 945.8717

Sign to Authorize Release of Medical Records

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PLEASE LIST BELOW ANY OTHER PHYSICIAN THAT YOU HAVE SEEN WITHIN THE LAST 5 YEARS.

Please List physician Name, Phone number, and Fax number

Patient Signature

Patient Signature

Patient Signature

Patient Signature

Patient Signature

Patient Signature