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Get and Sign Gastroenterology Intake  Form

Get and Sign Gastroenterology Intake Form

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Crohn’s large Severity type: mild moderate to severe fistulizing Has the patient had a NEGATIVE tuberculin skin test, or if positive, has treatment for latent TB been initiated prior to anti-TNF therapy? yes no Test Date: ________ Other: ___________________________________________ Does the patient have NYHA Class III/IV CHF? yes no Does the patient have a clinically important active infection? yes no ______________ For moderate to severe Crohn’s disease: Has patient failed/contraindicated...
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