! Thank you for including Lane Community College Health Clinic as part of your

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Welcome to the Lane Community College Health Clinic!! Thank you for including Lane Community College Health Clinic as part of your healthcare team. We provide accessible, high-quality medical treatment in a timely, caring, and compassionate manner to the students and staff of Lane Community College. We look forward to working with you to improve your health and meet your healthcare needs. Prior to your first appointment, please complete the attached new patient paperwork. Please bring the completed paperwork to your first appointment, along with a current insurance card and photo ID. On the day of your first appointment, please arrive twenty (20) minutes prior to your scheduled appointment time for check in. If you have any questions, please contact our office staff at (541) 463-5665. Thank you, The Lane Community College Health Clinic Staff!

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PATIENT INFORMATION L#: Appointment Date: Name: Date of birth: State or Country of Birth: Natal Gender (the physical gender you were born with): Your name, date of birth, and natal gender are used to determine your healthcare needs and to bill your insurance. If the information provided does not match your photo id and/or your insurance card, we may not be able to bill your insurance for your visit. Local Address: Mailing Address: City/State/Zip: City/State/Zip: Contact Phone: ( ) - Can we leave a message on this phone regarding your healthcare? Email Address: Primary Care Provider (PCP): Mother s Maiden Name & First Name: Patient s Maiden Name or Other Names: Emergency Contact Name: Relationship: Emergency Contact Phone: The following information is optional but allows us to provide more respectful care to our patients. Preferred First Name or Nickname: Gender Identification: Preferred Pronoun:

My Medication Log - Keep it Handy List all prescriptions, over-the-counter drugs, vitamins and herbs. Bring this to every doctor's appointment and If you go to the emergency room or hospital. Date: How Much and How Often? Reminder: This Medicine Name and Dose of Morning on Evening Bedtime When do I take it? is for Your Medicine Q my /Y") "',,, u E,c.,..1Mple: E,c.,..1Mple: E,c.,..1Mple: E,c.,..1Mple: ilmv<'\s\-<'1\-i\\ 40 IM l \i I-\ cl-\oles\-evol I pill A \-ev I 't,vv.sl-\ IMY \-eel-i-\ ; i g If you have any problems with your medicine - do not wait. Talk to your health care provider right away. Name of Primary Primary Care Provider Patient Name: Care Provider:--------------- Phone Number: -----------

Medical History Form (Please complete entire form before your visit) Today s Date: Patient Name (Please Print): Date of Birth: Occupation: Previous Occupations: Date of Last Examination: Marital Status: Married Single Separated Divorced Domestic Partner Widowed Personal History: (Update Annually) ALLERGIES TO MEDICATIONS: 1. 2. 3. 4. MEDICATIONS: List all, including over-the-counter 1. 2. 3. 4. 5. 6. 7. 8. HOSPITALIZATIONS & SURGERIES: 1. 2. 3. 4. 5. 6. 7. 8. Immunization History: Pneumonia Vaccine: Date: Routine Childhood Immunizations: Gardasil Vaccine: Date: TDaP Vaccine: Date: Flu Vaccine: Date: Year Personal Habits: (Update Annually) Exercise (type and how often): Work: Hours/Day Indoors or Outdoors Do you enjoy your work? Participate in Sports/Hobbies? Caffeine (coffee/soda)? # cups/day Number of hours of sleep per night: Do you have any safety issues at home? Personal and Family History: If applicable, please note WHO has had problem: M=Mother, F=Father S=Sister, B=Brother, MGM=Maternal Grandmother, MGF=Maternal Grandfather, PGM=Paternal Grandmother PGF=Paternal Grandfather A=Aunt, U=Uncle, C=Children If deceased, age at death: Alcoholism: Anemia: Asthma: Cancer or Tumor: Clotting/Bleeding Problems: Diabetes: Epilepsy: Gout: Heart Problems: High Blood Pressure: Mental Illness/Depression: Rheumatism or Arthritis: Stroke: Thyroid Problems: Other: SELF WHO AGE Please list any problems you are having at this time: 1. 2. 3. 4. Do you have a Living Will/Advanced Directive? If not, would you like to discuss this with your doctor? Routine Checkup - Problems Alcoholic beverages? If yes, what type and how many drinks daily? Have you ever been treated for alcoholism? Have you ever been treated for drug abuse? Have you ever used recreational drugs? If yes, what type, how often and last date? Tobacco: Cigarettes # packs/day Cigars Pipe Chewing Tobacco Snuff e-cigarettes If you have smoked in the past, when did you quit? CONTINUE ON OTHER SIDE

Personal History continued: For annual exam, please update information Please mark an X in the appropriate blank spaces FOR MEN ONLY: 46. Swelling, lumps or pain in your penis/testicles 47. Prostate problems, slow or weak urine stream 48. Burning or discharge from your penis 49. Last Colonoscopy: Date Where: FOR WOMEN ONLY: 49. Hysterectomy 50. Began having menopause symptoms 51. Vaginal discharge or pain 52. Irregular menstrual periods 53. Lumps or pain in your breasts 54. What was the date of your last menstrual period? 58. Date of Colonoscopy Date Where 55. When was your last pap test? 59. Last Mammogram Date Where 56. Number of pregnancies 60. Birth Control Method? 57. Number of live births 61. Have you ever had an abortion? te: This confidential record of your medical history will not be released without your written permission.

Consent / Release Form Consent for Medical Treatment I understand that by initialing this form, I am consenting to medical and/or surgical treatment including, but not limited to diagnostic tests, lab work, injections, minor operations, removal and disposal of tissues as may be deemed advisable or necessary by the attending health care provider. tice of Privacy Practices Acknowledgment I give Lane Community College Health Clinic (LCCHC) my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for health care operations such as quality reviews. I also agree that I have received a copy of LCCHC tice of Privacy Practices. Release of Information I authorize Lane Community College Health Clinic to release to my insurance carrier(s) by mail or fax, any information needed to determine benefits payable and bill for services provided. Informed of Ancillary Service Providers and Staff I understand that the LCC Health Clinic is part of an educational institution training health care professional staff and that, from time to time, I may have contact with students or other persons who may be observing or facilitating my care under appropriate supervision of clinical staff. Such persons may include, but not be limited to, students of the health profession, administrative or health care professionals, in orientation or training Assignment of Benefits I understand that this serves as a direct assignment of my medical benefits from Medicare, Medicaid, other government carrier, or any commercial/private insurance carrier, to be paid to LCCHC. *** If I receive payments directly from my insurance company, I agree to bring them to LCCHC for payment on my account. Cancellation / Show Policy I understand that I am expected to provide LCCHC with 24 hours notice if I am unable to attend my scheduled appointment. I understand that if I do not show for my scheduled appointments, I may be prevented from scheduling future appointments and instead be required to be seen on a walk-in basis. Financial Responsibility I understand that I am responsible for any non-covered services or services deemed not medically necessary by my insurance company. I understand that if I am unable to pay for services that I have requested, I will have those charges transferred to my L# account with Lane Community College. I further understand that it is the responsibility of my healthcare provider to notify me if a non-covered service is required and to give me the option to decline this service. My signature below indicates I have read and agree to any section above that is initialed. Patient Signature: Date:! Patient Name (Printed): L#:

PATIENT RIGHTS AND RESPONSIBILITIES Patient Rights 1. You have the right to considerate, respectful care. 2. You have the right to have us explain diseases, treatment, and results in an easy-tounderstand way. 3. You have the right to expect that all communications and records about your health care will be treated as confidential, respectful of legal requirements. 4. You have the right to refuse treatment, as permitted by law, and to be informed of the medical consequences of that action. 5. You have the right to voice any concern or complaints that arise, without fear, regarding your health care with your provider or a staff member. 6. You have the right to receive nondiscriminatory care regardless of race, creed, color, religion, gender, gender orientation, national origin, disability, or age. 7. You have the right to involve yourself or your family in any aspect of your care. Patient Responsibilities 1. Give your provider, clinic staff, and fellow patients respect and consideration. This includes no shouting, threats, cursing, or violence of any kind. 2. Provide complete, accurate, honest information about your health so that the staff can give you the best health care possible. 3. Keep your scheduled appointments or reschedule those appointments in advance. 4. Follow through with your care plan, including follow-up appointments, labs, and completing medications. Be sure you leave every visit with a clear understanding of expectations, treatment goals and future plans. 5. Let us know if you are unable to take your medicine or follow through with your care plan. 6. Discuss your concerns with the provider or a staff member should problems arise. 7. Treat the staff and clients / patients in the Clinic without discrimination regardless of race, creed, color, religion, gender, gender orientation, national origin or age. 8. Be active in your health care decisions. This includes involving your family and/or other trusted adults in any aspect of care that you feel would benefit your care. 9. Understand that your lifestyle choices effect your personal health. 10. Give us feedback so we can improve our services.

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