Medical Update. ~OBGYN AOA family of obgyn physicians YIN. Full Name (First, Middle, Last): Nickname: _ Age: _

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1 ... MARICOPA ~OBGYN AOA family of obgyn physicians Medical Update Date: _ For office use only Abstracted ( Y/ N ) Full Name (First, Middle, Last): Nickname: _ Age: _ Primary Care Physician: _ Phone Be aware that insurance companies do not allow you to be seen for pap/annual/wellness care on the same day that you have a specific complaint/problem that needs to be addressed. List all current medications None --- Drug Allergies: None _ Medication Dose Drug Reaction Herbal Supplements _ Vitamins Y / N Calcium Y / N Current Medical Problems Surgery in past two years Condition/Treatment Date Procedure Date Review of Systems - Any Complaints with (Y/N) Heart Yes No Joints Yes No Lungs Yes No Skin Problems Yes No Breasts Yes No Weight Yes No Bowels Yes 1\10 Vision/Hearing Yes No Kidneys/Bladder Yes No Headache Yes No Do you have any bladder concerns (leaking, pain, etc)? YIN Are you allergic to Latex? YIN

2 GYN History LMP _ Menstrual Cycle: Regular I Irregular # of days bleed _ Onset of Menopause (year) _ Do you want to be checked for STDs? YIN Have you had an abnormal pap in the past 10 years? YIN Social History Do you smoke? YIN Amount Daily How many years _ Alcohol Use? Daily I Occasionally I Rarely I Never Health Maintenance History PAP Smear Mammogram Dexa Scan (Bone Density) Cholesterol Colonoscopy Never Date of Last Abnormal Results/ Date & Treatment Family History: No family History available _ I am adopted _ Condition Yes or No Which Relative Heart Problems High Blood Pressure Diabetes Breast Cancer Ovarian Cancer Colon Cancer Other Conditions

3 OBSTETRICAL MEDICAL HISTORY Patient Name: Date Form Completed: Personal Health History 1. Are you allergic to any medications? If yes, please list: _ Physician Notes 2. Please mark any condition that you have or have had in the past: o Epilepsy 0 Thyroid Disorder 0 Asthma 0 Hepatitis o Heart Disease 0 High Blood Pressure 0 Diabetes 0 Herpes D Kidney Disease 0 Recurrent Urinary 0 Arthritis 0 Migraine o Headaches Tract Infections or Lupus Headaches o Blood Disease 0 Frequent Infections 0 Depression 0 Bowel Disease Describe, if needed: _ 3. Please describe any health problems that you are having at this time: _ Exposures Affecting Health 1. Do you smoke cigarettes? If yes, how many packs per day? 2. Do you drink alcoholic beverages? If yes, how often? What type of drink(s)? _ 3. Please list any "recreational" drugs used since your last period: (i.e. cocaine, marijuana, etc.) 4. Do you have a history of blood transfusion, intravenous drug use, multiple sexual partners or sexual exposure to a gay or bi-sexual male, exposure to an intravenous drug user, or have any other reason to believe you may have been exposed to AIDS? 5. Please list any sources of chemical or radiation exposure that you encounter: 6. If you are on a restricted diet, please describe? Gynecologic Health History 1. When was your last Pap Smear? Have you ever had an abnormal Pap Smear? If yes, when and where were you treated? What was the diagnosis? 2. Have you ever had gonorrhea, chlamydia or pelvic inflammatory disease? If yes, when and where were you treated? _ 3. Have you ever had herpes? _ 4. Have you ever used an IUD (intrauterine device) for contraception? If yes, please indicate when. Did you have any problem with the IUD? Please describe: 5. Do you have a history of infertility? If yes, please describe when and treatment received: 6. Please list any other concerns you have related to your past health history: Do you have any religious objections to any form of medical treatment that you would like to make us aware of (i.e. refusal of blood transfusion): Patient Signature Print Name Date

4 OBSTETRICAL MEDICAL HISTORY Please list any medications taken since your last period: Patient Name: _ Previous surgery (including D&C, tonsils, etc.) YEAR SURGERY HOSPITAL FAMILY HISTORY & GENEriC SCREENING: 1. Have either you or the baby's father had a child born with a birth defect? If yes, please describe: 2. Did either you or the baby's father have a birth defect yourselves? If yes, please describe: 3. Please describe any abnormalities that have occurred in children in your family or the baby's father's family (for example, mental retardation, birth defects, deformities, or inherited diseases like hemophilia, muscular dystrophy, or cystic fibrosis). No No Yes Yes How is the affected child/person related to you? 4. Do either you or the baby's father have a history of pregnancy losses (miscarriages or stillborn)? No Yes If yes, have either of you had genetic counselling? No Yes No Yes If yes, have either of you had chromosomal studies? Where and results: 5. Some genetic problems occur more in couples with certain racial or ancestral backgrounds. Please check if either you or the baby's father is of one of these backgrounds: Jewish ancestry? No Yes If yes, have you had Tay-Sachs screening tests? No Yes Date: Result: Black? No Yes If yes, have you had Sickle Cell screening? No Yes 6. Please mark if anyone in your family has: Date: Result: Diabetes No Yes If yes, how is that person related to you? Bleeding disorder No Yes If yes, how is that person related to you? Hypertension No Yes If yes, how is that person related to you? Toxemia of Pregnancy No Yes If yes, how is that person related to you? 7, Please list any other concerns you have about birth defects or inherited disorders? 8. Will you be 35 or older at the time the baby is born? No Yes 9. Will the father be 50 or older? No Yes Patient Signature Print Name Date Physician Notes on Genetic Screen:

5 Cord Blood Collection Information Form It is required by the State ofarizona that you be infonned about opportunities to save your baby's cord blood at the time ofdelivery. The blood in the baby's cord is a rich source ofstem cells. These cells have been used to treat nearly 70 diseases including leukemia, other cancers, blood and immune system disorders fu'ld some genetic diseases. Researchers are studying their use for things such as heart disease, juvenile diabetes, brain injury and many more. You have only one chance to collect and save your baby's genetically unique cord blood. The collection is simple and painless from the cord and placenta after birt.'1 and doesn't interfere with baby's care. Currently there- are over twenty family banks which store your baby's blood frozen specifically under your name and charge you for this ($1000 to $2000 and then annually $100 to $150). There is one public bank which accepts donations (Cryobank International). The blood is stored anonymously and categorized by cell type there. It might not be available specifically for your child in the future. If the blood is not saved, it is medically disposed ofwith the placenta. There are occasional problems atthe time ofcollection which result in inadequate samples. See also the AZ Department ofhealth Services brochure for further infonnation. There is also available material from the banking companies. I acknowledge I have been informed about the option oi saving my newborn's umb~lical cord blood for my family and received the AZDHS information. Should I wish further information about umbilical cord blood preservation orto enroll with a cord blood bank, I fully understand this responsibility will solely and completely be my own. Patient Name (print) Signature Date

6 ... MARICOPA ~OBGYN AOA family of obgyn physicians Ultrasounds during Your Pregnancy When your prenatal care begins, an ultrasound is performed to confirm the health of your pregnancy, the number of babies and your due date. If you are less than 14 weeks pregnant a vaginal ultrasound will help us get the best information. Women greater than 14 weeks will have an ultrasound through the abdomen. If you choose to obtain the first trimester screening test for Down's syndrome, you will have another ultrasound between 12 and 13 weeks. At 19 weeks, another ultrasound is done to more thoroughly evaluate your pregnancy. This ultrasound will confirm you due date, locate the placenta, measure the fluid in the uterus and survey the baby. Most ofthe time, but not always, the sonographer can determine the sex ofthe baby at this visit. However, the sex of the baby cannot always be determined accurately due the baby's position during the exam. In addition, ultrasounds, even though reassuring, cannot find all birth defects in babies. Additional ultrasounds will be performed in the last 20 weeks in your pregnancy when yourdoctor deems it medically necessary. For example, women with high blood pressure, diabetes, and twins will have more ultrasounds during their pregnancy. Please feel free to bring friends and family to your ultrasound. The ultrasound room at Maricopa OB/GYN can comfortably hold at least 5 visitors. If you are obtaining an ultrasound at an alternate facility, please ask in advance how many visitors you may bring. Please have children supervised so that you and your partner may. enjoy this peek into the uterus without distraction. Unfortunately, your ultrasound cannot be filmed or recorded. Photos of your baby are usually available for you to take home. Ultrasounds for Determination of Baby's Sex If we are unable to determine your baby's sex at your second trimester ultrasound and you desire this information, please let your provider know and our staff will schedule time for you.. Your health insurance will not cover this service consider since it is for your information only and not medically necessary. There is a $150 charge for this ultrasound. Payment is due on the day of your appointment. Please remember, the sex of the baby cannot always be determined due to the baby's position during the exam. We cannot guarantee we will be able to determine the baby's sex during the exam or the accuracy. Patient Signature: _ Date: _

7 FETAL TESTING INFORMATION Please read this important information carefully. Birth defects affect 3-4% of all pregnancies. Some, but not all, of the possible birth defects can be discovered by blood tests, ultrasound and genetic testing. The testing that you decide to perform for your pregnancy is an individual choice based on many factors such as your health, your age, your previous pregnancy experiences and your family's health history. There are two types of testing for your pregnancy: screening and invasive testing. Screening tests have no risk to the fetus or the mother. Screening tests include blood tests and ultrasound. Screening tests can identify a woman who is at higher risk than expected of having a baby with a birth defect, but cannot detect all of these birth defects (such as spinal cord defects or heart problems). Invasive tests have a very small risk to the fetus and an extremely rare risk to the mother. Invasive tests include chorionic villous testing and amniocentesis. Invasive tests can diagnose chromosomal birth defects in the fetus (such as Down's syndrome). First trimester weeks) screening tests include a blood test combined with an ultrasound. This testing can detect up to 85% of Down's Syndrome and up to 98% of Trisomy 13, Trisomy 18 and Turner's syndrome. The first trimester risk assessment is performed by a certified ultrasound center. Second trimester (15-21 weeks) screening tests include a blood test (MSAFP) done at weeks in our office. This test defines your risk for spinal cord defects (neural tube defects), Down's syndrome and Trisomy 18. An AFP test can be done for only spinal cord information or both spinal cord and Down's syndrome. At weeks an ultrasound will confirm your baby's growth, your due date and can detect 35% of fetal birth defects, but misses 65% of all birth defects. First trimester invasive testing is called a chorionic villous sampling (CVS). A small catheter is passed through the cervix under ultrasound guidance to obtain a small sample ofthe placenta which contains the baby's chromosomes. Results take 7-10 days. This test has a risk of miscarriage of 1 in 200. Second trimester invasive testing is called an amniocentesis. This test is performed by an obstetrician or obstetric radiologist by inserting a needle through the mother's abdomen into the uterine cavity. Fluid withdrawn from the uterus contains the baby's cells and chromosomes. Results take 7-10 days. This test has a risk of miscarriage of 1 in 250. All testing is optional and is your personal choice. Specially trained genetic counselors can help you decide if invasive testing is right for you. If you need additional information or referral to any ofthese counselors or doctors, we can help you.

8 FETAL TESTING PLAN Patient --'Age: --:EDC: _ First trimester screening (schedule with specialist) Second trimester blood test (MSAFP): (done at MOGA office) Chorionic Villous Sampling (schedule with specialist) Amniocentesis (schedule with specialist) Second trimester sono weeks weeks weeks weeks weeks Decline Accept My choice for testing is: 1. I decline all testing except ultrasound. 2. First trimester blood test and ultrasound 3. Second trimester blood test (MSAFP) 4. Second trimester ultrasound 5. Genetic counseling 6. Chorionic villous sampling 7. Amniocentesis 8. I am undecided today about what testing is right for me. I understand that all testing must be performed during strict time frames and that it is my responsibility to schedule and perform these tests at the correct time. If I miss a test time I understand that the opportunity to test may be lost. Any test that I have not accepted, scheduled and performed, I have declined to perform. Patient Date: Reviewed by: _ Date: MARJ-157 REV. 1110

9 CYSTIC FIBROSIS SCREENING Cystic fibrosis is a chronic, progressive, inherited disease of the body's mucus glands. This disease affects respiratory and digestive systems ofthe body. Cystic fibrosis patients require agreat deal ofcare and treatment, medicine and physical therapy, yet many patients often die ofthe disease at ayoung age. One out of every 29 Americans of Northern European descent is an unaffected carrier of the CF gene. Carriers are those who do not have any symptoms of the illness, but have the ability to pass that altered gene onto their offspring. People who should consider testing are: I.couples where one partner has CF 2. individuals who have afamily history of CF 3. non-jewish Caucasians and their partners 4. descendants ofashkenazijews 5. men with acongenital absence ofthe vas deferens Women ofother ethnic backgrounds are at risk too: Hispanics 1in 46 African 1in 60 Asian 1in90 Iftwo people are carriers for CF, they have a25%chance ofhaving ababy with the disease. Screening blood tests are available that may identify as many as 97% of people who are carriers for CF, depending upon their ethnic background. These screening tests may not be paid for by your insurance company. It is your responsibility to determine if your insurance will cover the test if it is interesting to you and your partner. Ihave been given information about cystic fibrosis screening and have had the opportunity to ask questions. I accept. _ Date _ I decline. _ Date _ MAR3-149 REV. 1/09

10 Consent for HIV Testing Information on HIV The Human Immunodeficiency Virus (HIV) is the virus that causes Acquired Immune Deficiency Syndrome (AIDS). HIV is spread through the exchange of blood, sexual fluids (semen and vaginal secretions) and sometimes through breast milk. HIV can be transmitted from mother to baby during pregnancy or childbirth. HIVTesting There are several laboratory tests for HIV. The most common is the antibody test, which is a blood test that detects antibodies produced by the body in response to infection with HIV. A negative antibody test indicates that no detectable antibodies are present in the blood. The absence of antibodies may be because an individual is not infected with HIV or because detectable antibodies have not yet been made in response to infection. The production of these antibodies could take three months or longer. Therefore, in certain cases, an individual may be infected with HIV and yet test negative. Persons with a history of HIV risk behaviors within the past three to six months should consider retesting. A positive antibody test consists of a repeatedly reactive (the same specimen testing positive twice) enzyme immunoassay (EIA) and a reactive Western blot (supplementary test). A positive antibody test means that an individual is infected with HIV; however, this does not necessarily mean that the individual has AIDS. Research indicates that early and regular medical care is important to the health of a person with HIV. Certain treatments are now available to delay HIV-associated illness. Means to Reduce Riskfor Contracting or Spreading HIV Risk of contracting or spreading HIV can be reduced by avoiding or decreasing contact with blood and sexual fluids (semen and vaginal secretions). Some methods of decreasing contact include abstaining from sexual intercourse, limiting the number of sex partners, properly using condoms during sexual intercourse, not engaging in injecting drug use or, if this is not possible, using bleach and water to clean needles and syringes. Disclosure oftest Results Positive HIV test results will be reported to the local and state health department. This information is protected by law and may be released only upon the tested individual's written authorization, for statistical purposes without individual identifying information, or as otherwise required or allowed by law. Additional Sources ofinformation on HIV Additional information regarding testing for HIV is available through your county health depart- ment and, in the Phoenix metropolitan area, (602) , the Tucson metropolitan area, (602) , or outside the Phoenix area, Consent My signature indicates that I acknowledge that I have received and understand the above information, and I voluntarily consent to and request HIV testing. Accept HIV Testing Patient Signature Date Decline HIV Testing Patient Signature MAR /02 Date

11 NOTICE OF MARICOPA OB/GYN PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY Uses and Disclosures Treatment. Your health information may be used by our staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staffmembers. Payment. Your health information may be used to seek payment from your health plan or from other sources of coverage such as an automobile insurer. For example, your health plan may request and receive information on dates of service, the services provided, medical condition being treated, and past medical history pertaining to the condition being treated. Your health information will also be used in obtaining benefit information and prior authorization for treatment and requesting and acknowledging referrals. Health Care Operations. Your health information may be used as necessary to support the day-to-day activities and management ofmaricopa OB/GYN. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality. Appointment Reminders. Your information will be used by our staff to contact you regarding appointment reminders. Law Enforcement. Your health information may be disclosed to law enforcement to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government-mandated reporting. Public Health Reporting: Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the states public health department. Other uses and disclosures require your authorization. Disclosure ofyour health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure ofyour information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us ofyour decision to revoke your authorization. MAR3-1S0 REV. 8107

12 Individual Rights You have certain rights under the federal privacy standards. These include: * the right to request restrictions on the use and disclosure ofyour protected health infonnation * the right to receive confidential communications concerning your medical condition and treatment * the right to inspect and copy your protected health infonnation * the right to amend or submit corrections to your protected health infonnation * the right to receive an accounting of how and to whom your protected health infonnation has been disclosed * the right to receive a printed copy of this notice Maricopa OB/GYN Duties We are required by law to maintain the privacy ofyour protected health infonnation and to provide you with this Notice ofprivacy practices. We also are required to follow the privacy policies and practices that are outlined in this notice. Right to Revise Privacy Practices As pennitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Upon request, we will provide you with the most recently revised notice on any office visit. The revised policies and practices will be applied to all protected health information we maintain. Requests to Inspect Protected Health Information You may generally inspect or copy the protected health infonnation that we maintain. As permitted by federal regulation, we require that requests to inspect or copy protected health infonnation be submitted in writing. You may obtain a fonn to request access to your records by contacting our check in desk or our privacy officer. Your request will be reviewed and will generally be approved unless there are legal or medical reasons to deny the request. Complaints Ifyou would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to: Privacy Officer Maricopa OB/GYN 1661 E. Camelback Rd., Ste. #160 Phoenix, AZ Ifyou believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause ofyour concern to the same address. NAME DATE