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PATIENT REGISTRATION Patient Home Phone ( ) - Address Work Phone ( ) - City State Zip Cell Phone ( ) Birthdate Social Security # - - DL# E-Mail Address How did you hear about us? Billboard, Phone Book, Intranet, Fly the Flag, Face Book, Individual Other Patient s Employer Employer s Address City State Zip How Long? Phone ( ) Dept. /Ext Spouse s Name D.O.B. Soc. Sec# - - Spouse s Employer Phone # ( ) How Long? Employer s Address City State Zip PERSON TO CONTACT, OTHER THAN SPOUSE, IN CASE OF AN EMERGENCY Name Relationship Address Phone# ( ) What Provider will you be seeing? What kind of insurance do you have? Race: American Indian or Alaskan / Asian / Black / Caucasian / Declined / Other / Pacific Islander Ethnicity: Hispanic / Non-Hispanic / Declined Language: Marital Status: Single Divorced Widowed Married Legally Separated

Acknowledgement of Review of Notice of Privacy Practices I have reviewed this office s Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document. * * Yo he leído la Noticia de Practicas Privadas, que explica como mi información medica será usada y distribuida. Yo entiendo que tengo el derecho de recibir una copia de este documento.* * Patient s Printed Name / * Nombre del Paciente * Patient s Social Security Number Patient s Date of Birth / * Fecha de Nacimiento * Date / * Fecha * Description of Personal Representative / * Relación al Paciente * Additional person(s) authorized to receive any personal information/ *Personas adiciónales a quien podemos dar información personal* I hereby assign to Athens Women s and Children s Center., and any assistant surgeon and/or anesthesiologist of his choice, all money to which I am entitled for medical/or surgical expense relative to the service rendered by him, but not to exceed my indebtedness to said physicians and/or surgeons. I understand I am financially responsible to said doctors for charges not covered by this assignment. I further agree in the event of non-payment, to bear the cost of collection, and/or court cost and reasonable legal fees should this be required. I authorize any holder of medical information about me to release to my insurance carrier and its agents any information needed to determine these benefits or the benefits payable for related services. * * Yo acuerdo dar a Athens Women s and Children s Center., y cualquier asistente cirujano y/o anestesiólogo de su escoger, todo dinero debido para crujías o asistencia médica relacionado al servicio dado por él, pero que no exceda mi deuda a dichos doctores y/o cirujanos.* * * * Yo entiendo que soy financieramente responsable a dichos doctores por los cargos no cubiertos por este acuerdo. Yo consiento que en dicho caso de que no pague, asumo la responsabilidad de pagar el precio de colección, y/o precio de corte, y/ó precio razonable para asuntos legales si son necesarios. Yo autorizo que mi información médica sea dada a mi seguro medico y sus agentes para determinar la necesidad de estos beneficios ó el pago de estos beneficios ó servicios relacionados. Signature of Patient or Personal Representative / Firma Date / Fecha

Accessing your medical information online Your access information To access your medical information, navigate to the Web page listed below and then enter your assigned username and password. Logging in To log in: Name: DOB: Web page: https://webview.mckesson.com/awcc Your username: Your password: 1. Go to the Web page listed above. 2. In the Username field, type your username. 3. In the Password field, type your password. 4. Click the Login button. The patient chart page appears. To view your chart information once you log in: On the left sidebar menu, click the item you want to view. The information appears in the center of the page. Logging out and exiting You should always log out of your online chart when exiting, especially if you are accessing the product from a shared or public computer To log out: Click the Logout link that appears at the top left side of the page. The login screen will appear, verifying that you logged out successfully.

I UNDERSTAND THAT MEDICAL PROVIDERS OF THE ATHENS WOMEN S AND CHILDREN S CENTER WHO WILL BE EXAM- INING ME INCLUDE PHYSICIANS, CERTIFIED NURSE MIDWIVES, ADVANCED NURSE PRACTITIONERS AND PHYSICIAN ASSISTANTS. Advanced Nurse Practitioners are professional nurses educated to provide the full range of primary care services in the community and hospital settings. They are certified by the American Nurses Association or by nursing specialty organizations. They hold licenses from the state as Registered Professional Nurse Practitioners. Physician Assistants are skilled members of the health care team who are educated to work dependently with physicians and under their supervision provide diagnostic and therapeutic patient care. Certified Nurse Midwives are individuals educated in the two disciplines of nursing and midwifery, who posses certification according to the requirements of the American College of Nurse Midwives. In addition in the state of Texas, they hold license as Registered Nurses and Advanced Nurse Practitioners. I understand that I may request to be seen by a physician. I authorize release of any information required for payment of provider and/or hospital charges for services rendered by the Athens Women s and Children s Center or by one of its clinics. I further authorize release of information to any hospital or medical facility I present myself to for medical care. Yo he leído la información contenida al reverso de esta página en español y creo que la entiendo completamente. Todas mis preguntas en este tema/asunto han sido completamente contestadas. Patient Name Date of Birth Patient s Signature/ Firma del Paciente Date/Fecha Guardian s Signature/Firma del Tutor Date/Fecha

NAME: DATE OF BIRTH: REASON FOR VISIT: REFERRED BY: Patient History Form OBSTETRIC HISTORY Year M/F Weight Length of Pregnancy Type of Delivery Problems # of Pregnancies # of Full-Term Deliveries # of Premature Deliveries # of Miscarriages/Ectopics # of Abortions GYNECOLOGIC HISTORY Age of first period: Last menstrual period: Cycles: every days Cycles are: Regular Irregular lasting days Flow is: Light Moderate Heavy Painful Sexual preference: Heterosexual Birth control method: Homosexual Any history of sexually transmitted diseases? Y N Bisexual Last Pap Smear: Any history of abnormal tests? Y N Last Mammogram: Any history of abnormal tests? Y N Last Bone Scan: Any history of abnormal tests? Y N Last Colonoscopy: Any history of abnormal tests? Y N

MEDICAL HISTORY Have you ever had any of the following? High Blood Pressure Heart Disease/Attack Stroke Blood Clots High Cholesterol Diabetes Liver Disease Bleeding Problems Asthma Migraines Thyroid Disease Depression/Anxiety Cancer Other: SURGICAL HISTORY Please list all of your surgeries: MEDICATIONS Please list all of your current medications & vitamins: ALLERGIES Please list all of your allergies: None SOCIAL HISTORY Marital status: Religion, if any: Occupation: Any abuse, emotional or physical? Y N Do you exercise? Y N Type & frequency: Do you drink caffeine? Y N How much? Do you smoke? Y N How much? Do you drink alcohol? Y N How often? Do you use drugs? Y N Which ones? FAMILY HISTORY Has anyone in your family ever had any of the following? High Blood Pressure Heart Disease/Attack Breast Cancer Uterine Cancer High Cholesterol Diabetes Colon Cancer Ovarian Cancer Blood Clots Down Syndrome Cystic Fibrosis Tay-Sachs Disease Bleeding Problems Neural Tube Defect Sickle Cell Disease A/B-Thalessemia

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