PATIENT'INFORMATION'!

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PATIENT'INFORMATION'! ' Referred By: Date: PharmacyName,PhoneLocation: LastName: FirstName: MiddleName: DateofBirth: Gender: SSN: MaritalStatus: DriversLicense: PrimaryLanguage: Race: _ AmericanIndian/AlaskaNative _ Asian _ Black/AfricanAmerican _ NatHawaiian/NativeIslander _White _ OtherRace _ Decline Ethnicity: _HispanicorLatino _NotHispanicorLatino _Decline Address: Apt# Zip: City: State:_ PreferredPrimaryPhone:( ) Type: Second:( ) Type: EmployerName: Occupation: EmergencyContact: Relationship: Phone:( ) Patient Portal _Yes Email Address: No INSURANCE'INFORMATION' ' PrimaryIns.Co: InsType:(Checkone)HMOPPOWCMVAEPOOTHER EffectiveDate: Policyholder: DOB: RelationshiptoPatient: ID#: Group#: PolicyholderSS#: PolicyholdersEmployer: Address: SecondaryIns.Co: InsType:(Checkone)HMOPPOWCMVAEPOOTHER EffectiveDate: Policyholder: DOB: RelationshiptoPatient: ID#: Group#: PolicyholderSS#: PolicyholdersEmployer: Address:! Assignment'of'Benefits,'Eligibility'Guarantee'and'Missed'Appointment'Policy' IrequestthatpaymentofauthorizedinsurancebenefitsbemadeonmybehalftoSanDiegoSportsMedicineandFamilyHealth Center(SDSMFHC)foranyservicesrendered.IauthorizeSDSMFHCtoreleasetomyinsuranceplananditsagentsany informationneededtodeterminethesebenefits.iherebycertifythatiameligiblefortheabovenamedhealthplanand,if applicable,havechosenaphysicianfromsdsmfhctobemyprimarycarephysician.iunderstandthatifiamnoteligibleunder thetermsofmyhealthplan,iamliableforallchargesforservicesrendered.ialsoagreetopayinfullforallnonxcovered serviceswithin30daysofnotificationofnonxcoverage.i authorize SDSMFHC to obtain information as needed from other medical providers and pharmacies in order to provide safe and comprehensive health care. IunderstandthatSDSMFHCwillchargea $25.00feeformissed appointmentsscheduledthatarenotcancelledwithatleast24hoursnotice. SignatureofPatientorParent/Guardian/Policyholder Date

AUTHORIZATION TO TREAT A MINOR For patients under age 18 In the event of a medical emergency, I authorize the physicians and staff of San Diego Sports Medicine and Family Health Center to provide necessary medical care to the patient named on the reverse side of this paper, if the parent/guardian is unable to be reached for authorization. I understand this authorization is revocable at any time by notifying San Diego Sports Medicine and Family Health Center in writing. Please sign below if you would like this authorization on file: Signature of Parent/Guardian Date. ADVANCE DIRECTIVES For patients age 18 and over A federal law requires us to give you information about your rights to make health care decisions. Your doctor must tell you about your medical condition and about what different treatments can do for you, and how you can plan what should be done when you cannot speak for yourself. In the event you become too sick to make medical decisions, it is helpful if you say in advance what you want to happen with your medical treatment. There are several kinds of advance directives that you can use to say what you want and who you want to speak for you. If you would like more information about advance directives, please notify your nurse or doctor. We have additional information to assist you in making these important decisions. Please sign below acknowledging the availability of information regarding Advance Directives. Signature of Patient over age 18 Date.

First and Last Name:_ DOB: / / Gender: Phone No.: Past Medical History (Please check any of the following that you presently have or had in the past and write the approximate date) Asthma Arthritis Allergies Anemia Alcoholism Cancer Colitis Depression Diabetes Epilepsy Fractures Headaches High Blood Pressure Heart Disease Kidney Problem Major Injuries Mental Illness Obesity Osteoporosis Strokes Thyroid Problem Tuberculosis Ulcers Other No pertinent history Past Surgical History (Please check all of the following surgeries you have had. For all surgeries, please enter date or surgery. If actual date is unknown, please put approximate date) Abdominal Arm Back Brain Breast Caesarian Cardiovascular Eye Finger Foot Hand Head Hip Hysterectomy Knee Leg Lung Neck Shoulder Vasectomy Other No Surgeries Current Medications (Please list all current medications, including dosage and how often you take it) Medication Allergies (Please list all current allergies to medications) No Medication Allergies Family Medical History (Please check any of the following that any of your relatives have or had. For Family History, please indicate which family member has this and which side of your family they are from. Include any applicable dates and ages) Asthma Arthritis Allergies Anemia Alcoholism Cancer Colitis Depression Diabetes Headaches High Blood Pressure Heart Disease Kidney Problem Mental Illness Obesity Osteoporosis Strokes Suicide Thyroid Problem Tuberculosis Ulcers Other (please continue on reverse) No Pertinent History

Reproductive History Age Menarche: Menses Duration: Last Menstrual Period: Menopause Status: Method of Birth Control: Age Menopause: Breakthrough Bleeding: Pregnancy Summary Total: Full Term: Premature: Abortion Induced: Abortion Spontaneous: Ectopic: Living: Birth History (Please enter your personal history or your child s birth history if filling out for your child) Full term(38-40 weeks): Vaginal or Caesarian: Infections during Pregnancy: Birth Weight: Gestational Diabetes: Stay in NICU: If Yes, Why: Hypertension During Pregnancy: Breast or Bottle Fed: Social History Current Diet: Education Level: Current Exercise: Home Environment: (Whom do you live with) Marital Status: Military History: Occupation: Parents Siblings: Sleep: Stress: Alcohol Use: Caffeine Use: Tobacco Use: Other Substance Abuse:

Acknowledgement of Receipt of Notice of Privacy Practices San Diego Sports Medicine and Family Health Center 6699 Alvarado Road, Suite 2100 and 2101, San Diego, CA 92120 4010 Sorrento Valley Blvd., Suite 300, San Diego, CA 92121 1945 Garnet Ave., San Diego, CA 92109 Privacy Officer: Office Manager, Phone No. 619-229-3909 I hereby acknowledge that I received a copy of this medical practice's Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area, and that I will be offered a copy of any amended Notice of Privacy Practices at future office visits as any amendments are made. Signed: Print Name: Date: Telephone: If not signed by the patient, please indicate: Relationship: parent or guardian of minor patient guardian or conservator of an incompetent patient beneficiary or personal representative of deceased patient Name of Patient: Methods of Communication Request I request the use of the following methods of communication of information related to my personal health, treatment or payment for treatment. I acknowledge that I am responsible for updating this information as necessary. This request supercedes any prior request for methods of communication I may have made. Please select all that apply. Where you list more than one communication option, please indicate which you prefer. Phone You may contact me by telephone at May we leave messages concerning results of laboratory work, other diagnostic testing, or referrals to other providers on your answering machine or with someone in your household? Yes No Do you wish for our physicians and staff to have detailed conversations concerning your health care and condition with family members or designated others? Yes No Name Relationship Name Relationship Mail (at the address provided on the registration paperwork) E-mail You may contact me at the following e-mail address: Fax You may contact me at the following fax number: (Not all physicians and/or staff have access to e-mail for the purposes of communicating with patients. By providing your e-mail address or fax number, you are authorizing our physicians and/or staff to communicate with you by e-mail or fax, the content of which may include protected health information. You agree that we are not responsible for the interception of those messages by others.) Signed: Date: Print Name:

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