Age: Birthdate: Date of Last Physical exam:

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1 Name: : Age: Birthdate: of Last Physical exam: SYMPTOMS: Check symptoms you currently have OR have had within the past YEAR. General Fever Chills Weight loss Weight Gain Headache Depression Vertigo Ringing in Ears Hay Fever Hoarseness Nosebleeds Difficulty Smelling Muscle/Joint/Bone Nausea Vomiting Rectal Bleeding Bowel changes Poor Appetite Bloating/Gas Constipation Dizziness Pain, Weakness or Excessive Hunger Fainting Numbness, Cramps Excessive Thirst Loss of Sleep Arms Hips Rectal Bleeding Nervousness Back Legs Vomiting Blood Numbness Feet Neck Skin Sweats, Night Hands Shoulders Bruise Easily Eye/ENT Cardiovascular Dry Skin Difficulty Swallowing Chest Pain Hives Persistent Cough Arm pain Itching/Rash Loss of Hearing Rapid Heart Beat Abnormal Mole Discharge Murmur/ Palpitations Discoloration Dry/ Irritation Swelling of ankles/calves Scars Sinus Problems High Blood Pressure Bleeding Gums Sores that won t heal Low Blood Pressure Psychological Blurred Vision Poor Circulation Crossed Eyes Irritability Shortness of Breath Double Vision/ Blurred Depression Gastrointestinal Earache Anxiety Hemorrhoids Ear Discharge Diarrhea Sleep Disturbance Light Sensitivity Stomach pain Suicide Thoughts MEN Only Breast Lump Erection Difficulties Lump in testicles Penis Discharge Sore on Penis Other Women Only Abnormal Pap Smear Bleeding between periods Breast Lump Extreme Menstrual Pain Hot Flashes Nipple Discharge Painful Intercourse Vaginal Discharge Do you feel safe in your relationship? Y N of Last Menstrual Period: of Last Pap Smear: Have you had a Mammogram? Are you Pregnant? Y N Number of Children CONDITIONS Check conditions you have OR have had in the past. AIDS Alcoholism Anemia Anorexia Appendicitis Arthritis Asthma Bleeding Disorders Breast Lump Bronchitis Bulimia Cataracts Chemical Dependency Chicken Pox Diabetes Emphysema Epilepsy Glaucoma Goiter Gonorrhea Gout Heart Disease Cancer Hepatitis I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. Signature Hernia Herpes High Cholesterol HIV Positive Kidney Disease Liver Disease Measles Migraine Headaches Miscarriage Mononucleosis Multiple Sclerosis Mumps Pacemaker Pneumonia Polio Prostate Problem Psychiatric Care Rheumatic Fever Scarlet Fever Stroke Thyroid Problems Tonsillitis Tuberculosis Ulcers Vaginal Infections Venereal Disease Reviewed By

2 Name: of Birth: Brief Description of your Problem (Symptoms, for how long?, etc.) Surgical/Hospitalization History: Past Medical History: List all medical conditions (Past & Present) managed by a Physician: Medications (including Non-Prescription Drugs): Medication Allergies: Social History: Marital Status: S M W D (Circle One) Education: Do you use Tobacco Products? Do you Drink: How Much/Type? Have you OR Do you use Illicit Drugs? Family History: Father - Age: If deceased, Age and Cause: Mother - Age: If deceased, Age and Cause: Brothers/Sisters - Age: If deceased, Age and Cause: State of Health: State of Health: How Much? State of Health: Any Illnesses that seem to run in the family: Type: Occupation:

3 PLEASE FILL IN ALL QUESTIONS AND PRINT CLEARLY Today s : Patient SS: of Birth: Cell Phone: Patient Name: Home Phone: Patient Address: City: State: Zip: Sex: Male Female Status: Single Married Divorced Widowed If Minor Please complete: Parent/Guardian: Contact Phone: Relationship to Patient: Address: City: State: Zip: Employer Information: Patient Employer: Employer Phone Number: Spouse Information: Spouse Name: Spouse SS # Person to Contact in Case of Emergency: Department: Spouse Contact Phone: of Birth: Ext: Name: Home Phone: Work Phone: INSURANCE INFORMATION Insurance Coverage: Yes No Cash Medicaid Medicare Is This Workers Compensation? / Accident Related? Yes No of Accident: Auto Work Other: PRIMARY COVERAGE Insured Party: Self Spouse Other/ Relationship: Insured Name: Insured SS#: of Birth: Insurance Name: Policy#: Group#: Insurance Address: City: State: Zip: Insurance Phone Number: Relationship to insured: SECONDARY COVERAGE Insured Party: Self Spouse Other/ Relationship: Insured Name: Insured SS#: of Birth: Insurance Name: Policy#: Group#: Insurance Address: City: State: Zip: Insurance Phone Number: Relationship to insured:

4 Patient Information Form ALL PROFESSIONAL FEES ARE DUE AT THE TIME OF SERVICE, UNLESS PREVIOUS ARRANGEMENTS HAVE BEEN MADE. Financial Agreement 1. Services are rendered to the patient, not the insurance company. As a courtesy, our office will file your insurance if proper information is received. A. You are responsible for co-pays, deductibles, non-covered services, co-insurances and items considered not medically necessary by your insurance company. B. For unpaid claims over 45 days, it is your responsibility to follow up with your insurance and the balance due is considered due and payable. 2. It is you re responsibility to notify our front desk staff of any insurance or address changes. 3. You will be responsible for any charges that occur if we are not notified. 4. Any debt incurred to collect a debt will be at the expense of the patient/responsible party. Patient Authorization I authorize College Station Med Plus to submit insurance claims using my signature on file below. I authorize the release of any medical information necessary in order to process this assignment on the claim. I authorize payment of medical benefits to be paid directly to College Station Med Plus for services describe on the claim form. I authorize College Station Med Plus to release any medical or billing information necessary, for treatment, payment or healthcare operations to the following family and or friends: (listed names and relationship) Patient Consent for E-Prescribing (Electronic Prescribing) I have been made aware and understand this office may use an electronic prescription system which allows prescriptions and related information to be electronically sent between my provider and my pharmacy. I have been informed and understand that my provider using the electronic prescribing system will be able to see information about medications I am already taking; including those prescribed by other providers. I give consent to my providers to see the protected health information. I choose the pharmacy below as my primary pharmacy: Pharmacy Name: Address: City, TX. Zip Patient Printed Name Preferred Lab:

5 Acknowledgement of Office Practices This office utilizes a Physician Assistant and/or Nurse Practioner to provide efficient delivery of health care. He or she will assist with patient care always under direct physician supervision. What are Physician Assistants and Nurse Practioners? Physician Assistants and Nurse Practitioners practice medicine under the supervision of physians and surgeons. Physician Assistants and Nurse Practitioners are formally trained to provide diagnostic, therapeutic, and preventative healthcare services, as delegated by a physician.. Physician Assistants and Nurse Practitioners take medical histories, examine and treat patients, order and interpret laboratory tests and x-rays and make diagnoses; they also treat minor injuries by suturing, splinting, and casting.. Physician Assistants and Nurse Practitioners record progress notes, instruct and counsel patients, they also prescribe certain medication. Authorization for Treatment I have read the above information and understand that this office utilizes Physician Assistants and Nurse Practitioners as part of the continuing care, and I authorize treatment by the Physician Assistants and Nurse Practitioners. Patient Printed Name Acknowledgement of Receipt of Notice of Privacy Practices I, (print patient name), hereby acknowledge that I have received and reviewed the Privacy Notice of College Station Med Plus. Print Name: Relationship to Pt.:

6 Acknowledgment of No Show Policy College Station Med Plus recognizes the need for a clear understanding between patient and physician regarding financial arrangements and standard office policies for your medical care. In order to provide you with the best and most efficient care, the following information is provided for you. If you have any question, please let us know before you sign this document. Cancelling or Rescheduling an Appointment: If you need to cancel or reschedule you appointment, you must notify our office at least 24 hours in advance of your already scheduled appointment. Failure to do so will be considered a No Show and result in a $25 fee for the first no show, $50 for the second and for each subsequent missed appointment thereafter. After the third missed appointment, you may be considered as a non-compliant patient and may be discharged from the practice. This fee is considered non-covered by insurance and you are responsible for the charge. Patients with Medicaid or Medicaid Products: Failure to appear for a scheduled appointment will be reported to Medicaid. Repeated no shows may result in loss of your Medicaid benefits. 15 Minute Policy: If you are more than 15 minutes late for your appointment, you may be asked to reschedule. I have read the above and agree to abide by this policy. I fully understand that failure to cancel and/or reschedule an appointment with less than a 24 hour notice, will be considered a No Show and as such will be subject to charge. Repeated No Shows may result in the termination of the Doctor-Patient relationship. Patient Printed Name

7 Welcome to College Station Med Plus We are pleased to be your choice for your healthcare needs. Please take a moment to let us know how you were referred to our practice. Today s : Printed Name: * We respect your privacy and this information will only be used internally and will not be sold or distributed. How did you hear about us? Another Physician o Please list the name of the physician Newspaper Magazine Radio Direct Mail Postcard Facebook Internet (Check one) o o CollegeStationMedAssociates.com CSMedCenter.com Yellow Pages Community Event Senior Circle Program Friend/Family Member Other Please return this form to the receptionist along with your other paperwork. Thank you!