..,.._, SOCIATES OF SURGERY

Dear New Patient:

4370 Medical Arts Dr STE 200 Flower Mound, Texas 75028

Phone: 972-219-6800 Fax: 972-219-0053

We look forward to seeing you at your upcoming appointment. Please fill out the enclosed paperwork and bring it with you to your appointment and give it to the receptionist when you sign in, along with your insurance card and picture ID.

We will make every effort to get all medical records that we need for your visit from your referring Physician. It is very important that those records are here in our office 24 hours prior to your appointment. If we do not receive them we may ask that you call your Physician and request them.

If you have any questions, please don't hesitate to call our office.

Again, we look forward to seeing you soon,

The Staff at Associates of Surgery

IF THERE IS PAPERWORK FROM YOUR EMPLOYER/DISABILITY INSURANCE THAT NEEDS TO BE COMPLETED BY OUR MEDICAL STAFF, THE FIRST SET OF PAPER WORK THERE WILL BE A FEE OF$25 A $10.00 FEE WILL BE CHARGED FOR ANY ADDITIONAL PAPERWORK THAT IS NEEDED.

IT IS VERY IMPORTANT THAT PAPERWORK BE FILLED OUT COMPLETELY.

ASSOCIATES OF SURGERY

PATIENT INFORMATION Date:

Last Name First Name Middle Initial DOB

Street Address (include apartment or space number if applicable)

City State Zip Code E-Mail

Home Telephone#: Work# Cell#

Social Security # __________ Male D Female D Marital Status

Race: Hispanic/Non-Hispanic Primary Language: ------------ (circle one)

FT, PT, Retired?

Employer/Occupation

Referring Physician Family Physician

How did you hear about our practice (phone book, internet, advertising, etc)

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MEDICAL RECORDS RELEASE

I hereby authorize the release of any and all medical records to the undersigned physician.

M.D.

SIGNATURE (PATIENT OR PARENT/GUARDIAN) DATE

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ASSIGNMENT OF BENEFITS

I irrevocably assign payment of medical benefits to the undersigned physician for services rendered.

M.D.

A photocopy of this assignment is to be considered as valid as the original. I understand I am responsible for all services rendered. I hereby authorize said assignee to release all infonnation necessary to secure payment.

SIGNATURE (PATIENT OR PARENT/GUARDIAN) DATE

ASSOCIATES OF SURGERY *PLEASE ANSWER ALL, IF NONE WRITE NONE OR N/A*

Patient Name DOB

Reason for visit:

PAST MEDICAL HISTORY: (CHECK ALL THAT YOU HAVE HAD IN THE PAST)

ACID REFLUX/HEARTBUR 1----1

ALCOHOLISM 1----1

ANXIETY 1---1

ASTHMA 1---1

1----1 BLEEDING DISORDERS

1----1 COLON PROBLEMS

1----1 SEIZURES/EPILEPSY

DEPRESSION 1----1

DIABETES

PAST SURGERIES:

ALLERGIES

N HEART PROBLEMS

DRUG ABUSE

HEPATITIS

HERNIA

HIGH BLOOD PRESSURE

HIGH CHOLESTEROL

HIV/AIDS

IRRITABLE BOWEL

KIDNEY PROBLEMS

LIV

LUN

ER PROBLEMS

G PROBLEMS

EMAKER PAC

PRO

SLE

STATE PROBLEMS

EP APNEA

THY ROID PROBLEMS

AST PROBLEMS BRE

CA NCER

OT HER

MEDICATION LIST:

--------------------------------------------------------------PHARMACY/LOCATION: -------------------------------------------------------MARITAL STATUS:

• ~~~ !!!!!!!!!;.

TOBACCO USE? YES D NO IF YES, HOW MUCH?

• ~·

CANCER? YES D NO IF YES, WHO/WHAT KIND?

HEIGHT:

ALCOHOL USE? DYES IF YES, HOW MUCH?

WEIGHT:

D NO STEROID USE? DYES D NO IF YES, HOW MUCH/WHEN?

HEART DISEASE? DYES D NO OTHER? IF YES, WHO? PLEASE EXPLAIN:

ASSOaATES OF SURGERY

Patient Name DOB ----------------------------------------- -----------------REVIEW OF SYSTEMS: (CHECK ALL SYMPTOMS THAT YOU HAVE NOW)

FEVER

CHILLS

WEIGHT LOSS/GAIN

FATIGUE

LOSS OF APPETITE

BODY ACHES

NIGHT SWEATS

EYES

CHANGES IN VISION

YELLOW EYES

HENT

HEADACHES

NECK STIFFNESS

NECK PAIN

NECK TENDERNESS

THYROID MASS

CHEST/BREAST

LUMPS

TENDERNESS

SWELLING

NIPPLE DISCHARGE

CARDIOVASCULAR CHEST PAIN

HEART MURM URS

IRREGULAR HE ART BEATS

RAPID HEART RATE

LIGHT HEADE D

GS/FEET SWELLING LE

SHORTNESS OF BREATH

WHEEZING

COUGH

ABNORMAL SPUTUM PRODUCTION

HOARSENESS

SLEEP APNEA

GASTROINTESTINAL

LOSS OF APPETITE

HEARTBURN

NAUSEA

VOMITING

EXCESSIVE BELCHING

BLOATING

DIARRHEA

CONSTIPATION

ABDOMINAL PAIN

JAUNDICE

BLOOD IN STOOL

HEMORRHOIDS

FATTY STOOLS

MUCOUS IN STOOL

NARROW STOOLS

EXCESSIVE FLATULENCE

GENITOURINARY

URGENCY

FREQUENCY

BLOOD IN URINE

PSYCHIATRIC

ANXIET y

DEPRESS

SUICIDA

ION

L

RASH

ITCHING

NEW SKIN LESIONS

CHANGES TO SKIN/MOLES

SKIN COLOR CHANGES

NEUROLOGIC

TINGLING/NUMBNESS

MUSCULAR WEAKNESS

INCOORDINATION

SEIZURES

LOSS OF BALANCE

MUSCULOSKELETAL

BONE PAIN

BACK PAIN

JOINT PAIN

LIMITATION OF MOTION

ENDOCRINE

COLD INTOLERANCE

HEAT INTOLERANCE

WEIGHT GAIN

WEIGHT LOSS

HOT FLASHES

HEME-LYMPH

EASY BR UISING

EEDING

LYMPHNODE

EASY BL

TENDER

INCONTINE NCE

IN

ss SCROTAL PA

HALLUC! NATIONS

SLEEPING TROUBLE

ENLARGE D LYMPHNODE

SCROTALMA