STEVEN C. DICKHAUT, M.D NE STALLINGS DR. SUITE 110 NACOGDOCHES, TEXAS PATIENT INFORMATON

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1 STEVEN C. DICKHAUT, M.D NE STAINGS D. SUITE 110 NACOGDOCHES, TEXAS PATIENT INFOMATON DATE: PATIENT S NAME: AGE: SEX : M ( ) F ( ) DATE OF BITH: SOCIA SECUITY #: ADDESS: STEET CITY, STATE ZIP CODE HOME PHONE: ( ) CE PHONE : ( ) CICE MAITA STATUS: M S D W PHAMACY (To be used for Prescriptions) ACE ETHINTICITY: HISPANIC NON HISPANIC ANGUAGE PATIENT S EMPOYE INFOMATION EMPOYE: OCCUPATION: EMPOYMENT STATUS: FU TIME ( ) PAT-TIME ( ) SEF ( ) ETIED ( ) ACTIVE MIITAY ( ) EMPOYE ADDESS: _ PHONE : ( STEET CITY/ST ZIP CODE ) EXT. PATIENT S SPOUSE INFOMATION SPOUSE S NAME: OCCUPATION: SPOUSE S SOCIA SECUITY#: SPOUSE S DATE OF BITH: SPOUSE S EMPOYE: PHONE: ( ) EXT. ACCIDENT/INESS INFOMATION COMPETE DATE OF ACCIDENT: WEE YOU INJUED: ON THE JOB ( ) AUTO ACCIDENT ( ) SCHOO INJUY ( ) OTHE ( ) BIEFY DESCIDE ACCIDENT: _ IF NOT AN ACCIDENT, GIVE DATE OF FIST SYMPTOM: HAVE YOU HAD THIS SAME O SIMUA INESS? YES ( ) NO ( ) IF YES, PEASE DESCIBE: *WE DO NOT FIE IABIITY CAIMS. UPON PAYMENT A ECEIPT WI BE POVIDED SO YOU CAN FIE FO EIMBUSEMENT. IF YOU HAVE ANY QUESTIONS PEASE SPEAK WITH THE FONT DESK.

2 OTHE PATIENT INFOMATION PESONA /FAMIY PHYSICIAN: EFEED BY: PAENT / GUADIAN INFOMATION PEASE COMPETE THIS SECTION IF YOU AE A COEGE STUDENT O UNDE 21 YS OD FATHE S NAME: OCCUPATION: EMPOYE: PHONE ( ) : EXT. MOTHE S NAME: OCCUPATION: EMPOYE: PHONE ( ): EXT. PAENT S HOME ADDESS: STEET CITY/STATE ZIP CODE PAENT S HOME PHONE: ( ): PEASE COMPETE THE INSUED S INFOMATION BEOW INSUED = PESON WHO CAIES THE INSUANCE IN THEI NAME INSUED S NAME: EATION TO PATIENT: _ INSUED S DATE OF BITH: INSUED S SOCIA SECUITY #: INSUED S EMPOYMENT STATUS: FU TIME ( ) PAT TIME ( ) ETIED ( ) INSUED S EMPOYE: PEASE EAD AND SIGN BEOW AUTHOIZATION TO EEASE INFOMATION: I hereby authorize Dr. Steven C. Dickhaut to release any information acquired in the course of my examination/treatment to my insurance carrier. I also authorize Dr. Dickhaut to release information to any hospital and physician I may be referred to by this office. In work- related injury cases, I authorize Dr. Dickhaut to release information to my employer. MEDICAE / MEDICAID / SECONDAY INSUANCE ASSIGNMENT OF BENEFITS: I hereby authorize payment directly to Dr. Steven C. Dickhaut for all medical services rendered. OFFICE POICY / ASSIGNMENT OF BENEFITS EGADING PIVATE INSUANCE AND PIVATE PAY: If my funding is private insurance or private pay, then payment is expected at time of service, unless prior arrangements have been made. I understand filing my insurance is a courtesy, and I am responsible for all costs of treatment including those of charges that exceed or are not covered by my insurance. On assigned claims, I hereby authorize payment directly to Dr. Steven D. Dickhaut for medical services rendered. I have read and understand the above statements. I agree to comply with the financial policies of this office. SIGNATUE: (PATIENT, PAENT, O GUADIAN): DATE:

3 PATIENT PEMISSION TO EEASE INFOMATION I,, give Dr. Dickhaut and his staff permission to release lab results, x-ray results, appointment information and other pertinent medical information, not including medical records, to the parties listed below. (Example: Parents, Spouse, Children, Guardian, Grandparents, etc.) Dr. Dickhaut and his staff will not release medical information, even verbally, to anyone not named on this form. Name elationship (Spouse, Child, etc.) EMEGENCY CONTACT INFOMATION Please list 2 people (not living in your household) that we may contact in reference to appointment rescheduling if you are unable to be reached. No medical information will be discussed with them unless they are listed above. NAME PHONE NUMBE I have reviewed the Notice of Privacy Practices of Steven C. Dickhaut, M.D. that explains to me the use and disclosure of my medical information. Signature Date

4 STEVEN C. DICKHAUT, M.D NE STAINGS D. SUITE 110 NACOGDOCHES, TX MEDICATION MANAGEMENT AGEEMENT I,, understand that this agreement is between Steven C. Dickhaut, M.D. and myself. It is designed to inform me fully of the manner in which my medications, especially narcotics, will be provided. It also outlines the criteria by which the doctor will determine whether or not to continue my medication. I understand that a reduction on the intensity of my pain and an improvement in my quality of life are the goals of this program. 1. Pain medications, especially of a narcotic type, will be provided only after it is determined that all reasonable alternatives for adequate pain control have been investigated/attempted. 2. I will agree to try other techniques as felt appropriate by the Doctor or Physician Assistant that may assist me in taking the lowest effective dose possible. 3. My pain medications will be prescribed by one doctor and one doctor only, and filled at one pharmacy. Any attempt, successful or not, to obtain additional medication without the permission of the doctor may result in discontinuation of medication therapy. 4. I agree to notify the doctor s office if I change my pharmacy for any reason. 5. Medications will be given at fixed intervals, and only if I keep my doctor appointments. 6. I understand no refills will be made after office hours or on weekend/holidays. 7. I agree that I will use my medication at a rate no greater than the prescribed rate and use of my medication at a greater rate will result in my being without medication for a period of time. 8. If your narcotics are lost or stolen, they will not be refilled until the due date. 9. Doctor and Patient agree that this agreement is essential for the Doctor s ability to treat the patient s pain effectively and that the failure of the patient to abide by the terms of this agreement may result in the withdrawal of my medication and the termination of the Doctor/Patient relationship. I have read and understand each of the above statements. I realize that he doctor will assume the responsibility of assisting me in my therapy as long as I comply with the above. Patient/Guardian Signature elationship to patient Witness Signature Date medmanagree.doc

5 Appointment Date: STEVEN C. DICKHAUT, M.D. 48OO N.E. STATINGS DIVE NACOGDOCHES, TX Patient Name (Please Print): Age Sex M Dominate hand Ambidextrous Did you bring X-AYS: Y N Who requested that you visit this office? Please check the ONE BOX that best describes the reason for your visit: Neck radiates to arm arm Neither Shoulder Elbow Hand Back radiates to leg leg Neither Arm Wrist Finger T Pelvis Hip Knee Ankle Self eferral Foot Toe B In this section, check the one box, which best describes how your problem started. Then answer the questions below the block that you checked. Use as much space to the right as needed. NO INJUY (Onset was Sudden) ANSWE O COMMENTS Why do you think it started? INJUY Sports related) Date: Where & How did it happen? What Sport? School? INJUY AT WOK Date: How did you injure yourself at work? AUTO ACCIDENT Date: How was your car hit? Your location in car? PEASE ANSWE QUESTIONS IN FOOWING BOX SO WE CAN HEP YOU BETTE: On a scale of 0-10 (10 is the worst) how severe is your pain? (Circle) What is the quality of the pain? Throbbing The pain is C Comes and Goes. Does the pain wake you from sleep? N Do you have Weakness? Since my problem started, it is Unchanged What makes your symptoms worse? Driving Pushing/ Pulling Sq Walking Which makes your symptoms better? est Other What medications are you taking now (or previously) for this problem? Have you had any of these treatments? N Were you seen in the E.. for this problem? N Which E..? Date: What test/scans have you had for this problem? EMG/NCV X-rays Current Work Status? Student

6 Patient Name (Please Print) EVIEW OF SYSTEMS: * AE YOU A DIABETIC N If yes, what treatment: None 4) AE YOU AEGIC TO ANY MEDICATIONS? N (If yes, please list and describe reaction.) PAST MEDICA HISTOY What medications do you take? None Please list with dosage Are you taking, or have you ever taken, blood thinners? N If yes which one? Past Surgical History: What operation have you had? None *Have you ever had: Cancer (location) COPD Heart Attack (year) High Blood Pressure High Cho Osteoporosis enal Failure None You may receive anti-inflammatory pills as a result of this visit. Have you had any of the following: Ankle Swellin Kidney Failure None What anti-inflammatories have you already had a problem with? SOCIA HISTOY: Do you use tobacco? N How many years? Packs per day? Alcohol Use? N How often? Other /week Marital History (Circle) S M D W HEIGHT: DO YOU WEA: Glasses WEIGHT: Contacts

Patient Information. Date of Birth Sex Marital Status / / Male Female Single Married Other. Address

Patient Information. Date of Birth Sex Marital Status / / Male Female Single Married Other. Address Patient Information Patient Information Date of Birth Sex Marital Status Male Female Single Married Other Social Security Number - - Why We Ask for Race and Ethnicity Patient Goes By: Email Address In