Your annual preventive visit, or complete physical exam, is scheduled with. Dr. on at AM/PM.

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Dear: Your annual preventive visit, or complete physical exam, is scheduled with Dr. on at AM/PM. Please bring the following with you on the date of your appointment: A list of your current medication(s), including strengths and dosage. (see enclosed form) A current health history, completed in dark ink. (see enclosed forms) Your current insurance card(s). No lab work is needed at this time. PLEASE HAVE YOUR LAB WORK DONE ONE WEEK PRIOR TO YOUR APPOINTMENT. You will need to fast for 12 hours prior to having your blood drawn nothing to eat or drink, except water. Take all your medications with water only. Please bring the enclosed lab slip to the lab when you have your blood drawn. Please confirm which laboratories are covered by your insurance by contacting your insurance provider. Valley Clinical Laboratory (affiliated with Oroville Hospital) has a draw station in our office. Your lab results will be ready for the doctor to go over them with you at the time of your appointment, avoiding the need for a return appointment and/or phone call for lab results. WOMEN: If it is time for your annual mammogram, please have this done prior to your appointment and have the results forwarded to our office. If you have any questions, please call us at (530) 894-0500. Thank you, Mission Ranch Primary Care

Mission Ranch Primary Care PATIENT INFORMATION Date: Patient s Name: Male / Female First Middle Last (circle) Race/ Ethnicity: Primary Language Spoken: Decline to State Date of Birth: Age: Marital Status: S M W D Sep Minor (circle) Home Address: City: State: Zip: Mailing Address: City: State: Zip: Main Contact Number: ( ) SS#: - - Driver s Lic. #: Alternate Number: ( ) E-Mail Address: OKAY TO LEAVE MESSAGES ON PROVIDED CONTACT NUMBERS? BOTH MAIN ALTERNATE Employed by: Occupation: Business Address: City: State: Zip: Phone Number: ( ) OKAY TO LEAVE MESSAGES AT WORK? YES NO Spouse s Name or (IF PATIENT IS A MINOR) Parents Name: Employed By: Occupation: Phone Number: ( ) EMERGENCY CONTACT: Nearest Relative/Close Friend NOT Living With You: Phone Number: ( ) Relationship to Patient: Please present your insurance card(s) with this completed form. Primary Insurance: Secondary Insurance: ASSIGNMENT OF BENEFITS-CONSENT FOR TREATMENT-RELEASE OF INFORMATION I hereby assign all medical and/or surgical benefits to which I am entitled, including Medicare, private insurance, and/or any other plan to Mission Ranch Primary Care. This assignment will remain in effect for one year from date signed. A scan and/or photocopy of this assignment will be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize said assignee to release information necessary to secure payment. I hereby authorize Mission Ranch Primary Care to perform any medical treatment deemed necessary. Signature: Date:

Family History Father D.O.B. If living, list health problems, i.e. heart disease, diabetes, cancer (including type) Age If deceased, list cause of death or major health problems Mother Siblings 1. 2. 3. Spouse Children 1. 2. 3. 4. When was your last (actual or best estimate of date): Preventive visit/ annual physical/ screening labs (which lab?) Vaccinations: Tetanus/Pertussis (Whooping cough, Td/Tdap) Flu Pneumonia Shingles/Zoster Screening tests (please include result, facility location, and planned follow-up, if applicable): Colonoscopy DEXA (bone density test) Women: Mammogram Pap Last Menstrual Period Please list all health problems: Please list any surgeries and hospitalizations, including date: Smoking history (current/past, amount, quit date Regular exercise (type and how often)? Hobbies: List any allergies (medication or other) and the reaction: Avg. weekly alcohol consumption

Please indicate if you have trouble or concerns with the following (including a brief explanation): Yes No Neurologic: Frequent headaches Change in vision Change in hearing Dizziness Difficulty walking Speech difficulty Numbness or tingling Cardiopulmonary: Chronic cough Shortness of breath Chest pain Heart palpitations Fainting Swelling of the legs/feet Gastrointestinal: Unintended weight loss Difficulty swallowing Heartburn, indigestion, reflux Abdominal pain Frequent nausea/vomiting Frequent diarrhea Frequent constipation Genitourinary: Pain with urination Frequent urination Incontinence (trouble holding urine) Getting up at night to urinate Blood in urine Sexual concerns Musculoskeletal: Muscle or joint pain Muscle weakness Dermatologic: Rash Warts Concerning or changing moles, bumps, lesions Please list any specific concerns you would like to address in the upcoming visit:

Prescription and Non-Prescription Medications (including vitamins and other supplements) I am not taking any meds or supplements Medication Strength Frequency (how often) Indication (diagnosis/reason) **Please attach a separate list if medications exceed the space provided** Physician Name Current and Recent Physicians (and other health practitioners or therapists) Specialty (and reason seen)

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