Pages 1 of 7

PATIENT INFORMATION SHEET UPPER GASTROINTERSTINAL ENDOSCOPY (EGD)

As part of your evaluation, your doctor has scheduled an upper gastrointestinal endoscopy. This procedure consists of passing a flexible instrument by mouth in order to visually examine your esophagus, stomach and first part of your small intestine. Your doctor may also take photographs and biopsies (small pieces of the intestinal lining to examine under a microscope). It is important that your stomach is empty for an adequate exam; therefore, you must not eat or drink anything after midnight the night before your procedure. Prior to the endoscopy, your throat will be sprayed with local anesthesia to prevent gagging, and you may receive sedative medication (usually Demerol and/or Versed) through a vein to make your examination more comfortable. Please inform your physician of any known allergies. Upper endoscopy is generally a very safe procedure, but certain complications are possible and should be mentioned. The possible complications include the following: 1). Undesired responses to medications used including allergic reaction and respiratory arrest 2). Excessive bleeding (requiring blood transfusion). 3). Perforation (hole in the wall of the intestine that might require surgery to repair) The medication you receive during the procedure impairs your judgment, perception and coordination the rest of the day. Also, a side effect of the medication is forgetfulness. Therefore, you will need a responsible adult to escort you from the hospital. We must verify your escort by speaking to them either by phone or in person BEFORE we begin your procedure. If we cannot verify your escort, your procedure will be cancelled. Following the procedure, you may have some belching and pass gas since air is introduced into your intestine during the procedure. If your have any questions, feel free to ask your doctor. Please sign this sheet prior to endoscopy, so that we know your questions have been answered and that you understand your procedure.

_________________________ Patients Signature

__________________________ Physicians Signature

_________________________ Date

___________________________ Witnesss Signature

WRAMC FORM 524 12 March 1993

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PATIENT INFORMATION SHEET DISCHARGE INSTRUCTIONS UPPER ENDOSCOPY (EGD)

You have just undergone an upper endoscopy (EGD). You were given medication to numb your throat and intravenous medication to make you relaxed and sleepy. Biopsies may have been performed. This information sheet is to remind you of the procedure and to ensure that your physicians instructions are followed. Your throat may be a little sore for a few hours and you will feel bloated for several minutes to hours after the procedure because of the air that was introduced into your stomach for examination. Localized irritation of the vein may occur at the site where your intravenous medication was injected. A tender lump may develop which may remain for several weeks to months but generally will disappear. This may be treated over the first several days with beating the area with a warm moist cloth for 15 - 20 minutes 3 - 4 times a day and elevation of the affected area. Should this become swollen or reddened, please contact your physician. You are asked not drive or operate a motor vehicle or other equipment for at least 24 hours. Your physician will inform you of any other time interval should it be appropriate. Complications from this procedure are rare but can occur. If you experience symptoms of progressive abdominal pain, recurrent nausea or vomiting, a fever greater than 101 degrees, vomiting or passing per rectum of blood, or other unusual symptoms, please contact your physician or have yourself taken to the nearest medical facility or emergency room for evaluation. You may resume your diet and routine medications after the throat anesthesia has worn off unless your physician instructed you otherwise. You should contact your physician 7-10 working days for results if any biopsies were taken or other tissue removed. Your physician is Dr._______________________, Gastroenterology Service, Walter Reed Army Medical Center, Phone (202)782-6765/66. The emergency room phone number is (202)7821199.

Pages 3 of 7 WALTER REED ARMY MEDICAL CENTER ADMISSION WORKSHEET

SECTION A: FOR ADMITTING PHYSICIANS USE
PATIENTS NAME SOCIAL SECURITY NUMBER WARD: _________________________ ADMISSION DATE/TIME: CLINICAL SERVICE CODE: ________________________ TYPE OF ADMISSION DIRECT OTHER TYPE CASE DISEASE ADMITTING PHYSICIAN INJURY E.R. MTF CODE NB TRANSFER

SIGNATURE

ATTENDING PHYSICIAN

ADMITTING DIAGNOSIS:

ADMISSION COMMENTS:

WRAMC FORM 1377 1Oct 94

Pages 4 of 7
REGISTER # DATE/TIME:

PATIENT NAME: FMP: SSN#

WARD: _________________________ CLINICAL SERVICE CODE: _________________________

SPONSOR INFORMATION
SPONSOR NAME: RANK:

MOS/AFC: DATE OF BIRTH: STATUS ACTIVE UNIT: RETIRED PHONE: ( )

LOS:

DECEASED

PATIENT INFORMATION
SEX

DATE OF BIRTH:

PATIENT CATEGORY

RELIGION:

RACE:

MARITAL STATUS:

COMMAND INTEREST:

RESIDENCE
STREET STATE ZIP CODE PHONE ( ) CITY HOME STATE

EMERGENCY CONTACT
NAME PHONE : ( STREET STATE ) CITY IS THIS NEXT TO KIN? YES NO RELATIONSHIP ZIP CODE

SECTION B: FOR ADMINISTRATIVE USE:

CLERK:

** Have you completed a legal documentation in which you give another adult the authority to make medical treatment YES NO decisions for you if you become unable to do so? *** I have been informed that any funds or valuables in my possession while a patient in this hospital are retained at my own risk and that I may should deposit same in the Patients Trust Fund. I $ DEERS: . DO DO NOT desire to make a deposit at this time. I also understand that my daily rate of charge is

__________________________________ Patients/Sponsors Signature

Pages 5 of 7

PATIENT RIGHTS AND ADVANCE DIRECTIVE INFORMATION

1. I understand that WRAMC provides a Patient Representative, and that this Representative is available to ensure my rights as a patient, to review any complaints I may have, and when possible, resolve my complaint(s). I have also been provided a pamphlet concerning Patient Rights and Responsibilities. Patient/Guardian Initials ____________

2. I understand that as a patient, in collaboration with my physician, I may expect to make decisions regarding my care, including the right to accept or refuse medical or surgical treatment and to be informed of any consequences. I may formulate advance directives; however, I am not required to have advance directives in order to receive care. I have been provided a pamphlet concerning advance directives, which includes sources for additional information about advance directives. I am also aware that blank forms to formulate advance directives are available in the Admissions Office. Patient/Guardian Initials _____________

3. I understand that the terms of any advance directives that I execute will be followed by WRAMC to the extent permitted by law and in accordance with policies and procedures. I also understand that the staff and physicians of WRAMC will not be able to follow the terms of my advance directive until I provide a copy of it to the staff. Patient/Guardian Initials ____________ 4.

YES
I have executed an advance directive for healthcare. I understand that it is my responsibility to provide this facility with a copy. If YES to question 4, a copy of my advance directive is attached to this information sheet.

NO

Patient/Guardian Initials ____

Patient/Guardian Initials ____

Patient/Guardian Initials ____

Patient/Guardian Initials ____

STOP! The Remainder of this form is for the use of the Health Care Provider________ Oral advance directive is documented in patients medical records. ______________________________ Signature of Health Care Provider
ADDRESSOGRAPH:

_______________________ Date
COMMENTS:

WRAMC FORM LETTER 714 1Oct 97

U.S. GPO 2002-494-623/61152

See Attached DD Form 2005 For Privacy Act Statement

Pages 6 of 7
PATIENT SCREENING FORM WRAMC FORM 716 Jul 02

PLACE A CHECK IN THE YES OR NO COLUMN AND UPDATE EVERY VISIT (Please Use Pencil)
1. Has it been more than a year since you completed a Hows Your Health Survey (HYH)? 2. Primary Language: 3. Are you experiencing pain at this time? 4. Do you need any educational information today? 5. What method(s) of learning do you prefer? (Select all that apply) One-on-One Instruction Group Instruction Reading Videos Demonstration Other: 6. Do you have any medical problems that make it difficult for you to understand medical information of instructions? 7. Learning Barriers: (Select all that apply) Hearing Vision Speech Cultural Motivation Religious None Other: 8. Do you have any religious customs, beliefs or rituals that may affect your medical care? 9. Are you taking any dietary supplements, herbal medications or vitamins? 10. Have you experienced a 10-pound or more change in weight in the past 6 months? 11. Do you have a medical problem that effects what you can eat? 12. Do you have difficulty chewing or swallowing foods or liquids? 13. Would you like to discuss nutritional issues with a dietician? 14. Do you have any problems performing your activities of daily living? (Activities such as dressing, feeding, grooming or bathing yourself or walking)

YES

NO

SIGNATURE OF PATIENT:

DATE:

PATIENT, PLEASE RECHECK & COMPLETE WITH EACH VISIT Has Your Information on This Form Changed Since Your Last Visit? Select ONE Patients Initials Date

YES Information Has Changed NO Information Has Not Changed

RETURN FORM TO HEALTH CARE TEAM

CONSULT(S): SELECT/ LIST TYPE & DATE SENT:

Pages 7 of 7
Dietary______________________________________ Pharmacy____________________________________

Wellness Center_______________________________ P.T. ________________________________________ O.T. ________________________________________ Other:___________________________________________________________________ Other: ___________________________________________________________________ Other: ___________________________________________________________________ PROVIDER RECHECK & COPLETE WITH EACH PATIENT VISIT PROVIDER SIGNATURE REMARKS/CONSULTS SENT

DATE

Maintain this form on inner left side of Outpatient Record

PATIENTS IDENTIFICATION: (For typed or written entries, give: Name last, first, middle; ID No. or SSN; Sex; Date of Birth; Rank/Grade.)

WRAMC FORM 716, Page 2 Jul 02