Surgical History (Please provide Month/Year for all that apply):

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1 DATE: Name: First MI Last Maiden Date of Birth: Reason for Visit: Primary Care Provider: Personal Medical History (PLEASE CHECK ALL THAT APPLY): Diabetes, Type 1 Seizures High Blood Pressure Migraine/Headaches c Diabetes, Type 2 c HIV/AIDS c High Cholesterol c Hepatitis c Gestational Diabetes c Frequent UTI s c Breast Disease c Depression c Heart Disease c Kidney Disease c Thyroid Disease c Anxiety c Stroke c Urinary Incontinence c Intestinal Disease c Complications with Anesthesia c Prior blood clot in legs or lungs c Asthma c Bowel Disorder c Chlamydia/Gonorrhea/Trich c Sickle Cell Disease/Trait c Lung Disease c Stomach Problem c Herpes c Arthritis c Skin Disease c HPV c Mitral Valve Prolapse c Blood Transfusion c Yeast c c c c Additional Illnesses: Surgical History (Please provide Month/Year for all that apply): Appendectomy Wisdom Teeth Lithotripsy Tonsillectomy Orthopedic Surgery Lung Gallbladder Bladder Brain Surgery Bowel Additional Surgeries:

2 Previous Gyne Surgical History (Please provide Month/Year for all that apply): Colposcopy Bilateral Tubal Ligation Ablation Cryotherapy Breast Augmentation LEEP Hysterectomy Cesarean Section D&C Cone Biopsy Breast Biopsy (Left / Right) Essure Removal of one or both ovaries Additional Surgeries: Gynecology History (Please complete all questions that apply): How old were you when you had your first menstrual period? Menopause? If you are currently having periods, what was the date of the first day of your last period? Do your periods occur regularly? How long do your periods typically last? How do you consider your menstrual flow? Heavy Moderate Light How do you consider your menstrual pain? Severe Moderate Mild Are you currently sexually active? If yes, are you sexually active with Men, Women, or Both? If so, how many partners have you had in the past 12 months? Do you experience any pain or bleeding with intercourse? What is your current method(s) of contraception? Past method(s) of contraception? Any problems? Obstetrical History (Please complete all questions that apply): Total Pregnancies: Full Term Deliveries: Preterm Deliveries: Elective Abortions: Miscarriages: Ectopic Births: Multiple Births: Living Children: Delivery Date Weeks Preg Length of Labor Birth Wt Sex Type of Delivery Name of Child Complications

3 Family Medical History (Please list Mother / Father / Sister / Brother / Maternal or Paternal Grandparents): Ovarian Cancer Heart Disease Diabetes Uterine Cancer Stroke Osteoporosis/Fractures Breast Cancer Hypertension Blood Clotting Disorders Additional Diseases or Cancer Types: Social History: Do you smoke: Yes No # of cigarettes per day: Do you drink alcohol? Yes No # of drinks: Frequency: Do you use recreational drugs? Yes No Type: Frequency: Are you employed? Yes No If yes, where? What is your marital status? Who do you live with? Do you exercise regularly? Yes No Type of exercise: Frequency: Do you consume caffeine regularly? Yes No # of drinks per day: Coffee / Tea / Soda / Other: Do you wear seat belts regularly? Yes No Routine Health Screening History (Please provide Month / Year for all that apply): Lipids Testing Normal Abnormal Thyroid Testing Normal Abnormal Other Blood Work Normal Abnormal Most Recent Pap Smear Normal Abnormal LSIL HSIL ASCUS ASCUS-H AGUS Unknown Previous Abnormal Pap Smear Abnormal LSIL HSIL ASCUS ASCUS-H AGUS Unknown Gonorrhea / Chlamydia Negative Positive RPR (Syphilis) Testing Negative Positive HSV (Herpes) Culture Negative Positive HSV (Herpes) Blood Testing Negative Positive HIV Testing Negative Positive Mammogram Normal Abnormal Bone Densitometry Normal Abnormal Colonoscopy Normal Abnormal Additional Health Screening:

4 Immunization History (Please provide all that apply): Flu Vaccine PneumoniaVaccine HPV Vaccine Zoster Vaccine Additional Immunizations: Please list all the medications and dosages that you are currently taking (prescription, supplements, and over-the-counter): Please list all medical allergies and symptoms (medicine, latex, etc): Please list all other allergies and symptoms (environmental, food, etc):

5 FINANCIAL POLICY We know that choosing a physician is a very important decision and we thank you for choosing our office. Please take a minute to carefully read this overview of some of our financial policies. INFORMATION REGARDING INSURANCE COVERAGE You must be informed of and understand the details of your health insurance coverage and fulfill any associated requirements (pre-certification, obtaining referrals, providing information regarding pre-existing conditions, etc). It is also your responsibility to provide our office with all required information regarding your health insurance coverage. It is important that you promptly notify us if there are any changes to your insurance information. If any complications arise during the billing process, you have an obligation to promptly provide assistance and information to our billing staff and if you fail to timely provide any information or assistance then we have the right to not submit the claim to your insurance company and you will be fully responsible for the balance. UNINSURED PATIENTS If you do not have current health insurance coverage, the entire payment for any services performed shall be paid at the time of service. NON-PARTICIPATING PROVIDER OR NON-COVERED BENEFITS If we do not participate with your health insurance carrier, or if the services provided are not covered under your particular health plan, then you are responsible for paying for all services at the time of service. If you would like us to do so, we can (upon your request and full payment) provide a statement for your records and/or reimbursement purposes. PARTICIPATING PROVIDER AND COVERED BENEFITS If we participate with your health insurance carrier and the services sought are covered services, we will directly bill your health insurance carrier. Under your plan, you may be responsible for paying certain amounts (co-payments, deductibles, and fees for non-covered services), which are due at the time of service. TYPES OF PAYMENT 5401 N. Knoxville Ave, Suite 114, Peoria, IL (309) OUR OFFICE ACCEPTS CASH, CHECKS, VISA, MASTERCARD, DISCOVER, AND AMERICAN EXPRESS. If your check is dishonored, you will be required to pay an additional fee of $35.00, which shall be due immediately.

6 COLLECTION OF OUTSTANDING BALANCES All outstanding balances shall be due within 30 days. All past due balances are due in their entirety, prior to or at the time of your visit. Balances that are 30+ days old will be assessed a finance charge that will accrue monthly until paid. Balances that remain outstanding for a period of 90 days or more may be referred to a collection agency or attorney s office. If your account is referred to a collection agency, you will be responsible for paying a collection charge equal to 40% of your outstanding balance, which is in addition to your outstanding balance. If your account is referred to an outside attorney, you will be responsible for paying all reasonable attorneys fees and court costs, which are in addition to your outstanding balance. To avoid all of this, please pay your bill in a timely manner. MISSED APPOINTMENTS It is important that you appear for all scheduled appointments. As a courtesy, we will call to confirm your appointment a day or two before the scheduled appointment. If speaking to you is not possible for any reason, we will attempt to leave a reminder message with a family member or on a voic . Failure to cancel your appointment within 24 hours deprives other patients of an opportunity to visit our office. A fee of $25 may be charged if you fail to appear for any scheduled appointment. This policy is aimed at minimizing the waiting time and ensuring availability of prompt medical care. We recognize that there may be circumstances which may not permit you to give a 24 hour notice and such circumstances are exceptional and shall be considered on a case-by-case basis. By signing below, the patient or responsible party acknowledges that he/she has read and understands the Financial Policy of Affinity Women s Health Care and agrees to be bound by the terms and conditions set forth therein. Signature of Patient or Responsible Party Print Name of Patient or Responsible Party Date

7 I,, hereby acknowledge receipt of the physician s Notice of Privacy Practices. The Notice of Privacy Practices provides detailed information about how the practice may use my confidential information. I understand that the physician has reserved a right to change his or her privacy practices that are described in the Notice. I also understand that a copy of any Revised Notice will be provided to me or made available in the office at my request. Signed: Date: If you are not the patient, please specify your relationship to the patient: 5401 N. Knoxville Ave, Suite 114, Peoria, IL (309)

8 Patient Privacy and Confidentiality Statement In order to ensure patient privacy and confidentiality, our office will not release information to friends or family members without written consent. Please list any family members or other persons, who we may inform about your general medical conditions and your diagnosis. Name Relationship Phone Number List the phone number, if any, you would prefer to receive calls about your appointments, any test results, or other health care information: Can appointment reminders or messages asking you to call our office be left on this phone number? YES NO Can we contact your place of employment to inform you of test results or other health care information? YES NO If you would prefer correspondence(s) from our office sent to an address other than your home address please provide the address: Print Name Signature Date of Birth Today s Date 5401 N. Knoxville Ave, Suite 114, Peoria, IL (309)

9 PATIENT INFORMATION Patient Name Last First MI Maiden Name Address Street City State Zip Home Phone ( ) Date of Birth / / Cell ( ) SS# / / Place of Employment Work # ( ) Preferred Hospital / LAB: OSF MMCI Proctor Lab One REFERRING / FAMILY PHYSICIAN Name Phone # ( ) SPOUSE / PARENT INFORMATION Name DOB / / SS# / / EMERGENCY CONTACT Name Relationship Phone # ( ) INSURANCE INFORMATION Primary Ins. Co. Group # Policy # Insured: Self Spouse Other (List relationship) Secondary Ins. Co. Group # Policy # Insured: Self Spouse Other (List relationship) I authorize payment of benefits, as determined by Affinity Women s Health Care. I understand that I may still be responsible for any amounts not paid by my insurance company in the event that the charges made are applied to my deductible, copay, or are not reasonable or customary. Signature: Date: I authorize any insurance company, organization, employer, hospital, physician, or pharmacist to release any information requested with regard to processing my claim. I certify that information I furnish is true and correct. I know it is a crime to fill out this form with facts I know are false or to leave out facts I know are important. Signature: Date:

10 RISK ASSESSMENT FOR LYNCH SYNDROME AND HEREDITARY BREAST AND OVARIAN CANCER SYNDROME Patient Name Today s Date Primary Care Physician Date of Birth This is a screening tool for cancers that run in families. Please consider BLOOD family members only when completing: [Mother/Father/Sister/Brother/Children = 1 st Degree Relatives] [Aunt/Uncle/Grandparent/Niece/Nephew = 2 nd Degree Relatives] [Cousin/Great Grandparent = 3 rd Degree Relatives] Have you or any of your relatives been tested for hereditary cancer (BRCA/Colaris) in the past? YES NO YOUR RELATIONSHIP TO FAMILY COLON AND UTERINE CANCER (Lynch Syndrome Colaris) SELF MEMBER WITH CANCER MOTHER S SIDE FATHER S SIDE Y N EXAMPLE: Two or more relatives with a Lynch Syndrome cancer; one under age 50 Aunt colon Sister uterine Y N Have YOU been diagnosed w/ uterine (endometrial) or colorectal cancer before age 50? Two or more relatives on the same side of the family w/ any of the following, one Y N diagnosed before 50 (please circle): colon, uterine/endometrial, ovarian, stomach, small bowel, pancreas, brain, kidney/urinary tract, ureter and renal pelvis Three or more relatives on the same side of the family w/ any of the following diagnosed at Y N any age (please circle): colon, uterine/endometrial, ovarian, stomach, small bowel, pancreas, brain, kidney/urinary tract, ureter and renal pelvis Y N Family member has a known Lynch Syndrome mutation AGE AT DIAGNOSIS 47 yrs 60 yrs BREAST AND OVARIAN CANCER (HBOC BRACAnalysis) Y N Breast cancer at age 45 or younger (in self, first or second degree family members) Y N Ovarian cancer at any age (in self, first or second degree family members) Y N Two relatives on the same side of the family w/ breast cancer - w/ one under the age of 50 Y N Three relatives on the same side of the family w/ breast cancer at any age SELF YOUR RELATIONSHIP TO FAMILY MEMBER WITH CANCER MOTHER S SIDE FATHER S SIDE Y N Multiple breast cancers in the same person (in the same breast or in both breasts) Y N Male breast cancer at any age Y N Ashkenazi Jewish ancestry w/ breast, ovarian or pancreatic cancer in the same person or on the same side of the family Y N Pancreatic cancer w/ breast or ovarian cancer in the same person or on the same side of the family Y N Triple Negative breast cancer under age 60 (ER, PR & Her2 negative receptor status) Y N A family member with a known BRCA mutation Is there any other cancer in you or any family member(s) not listed above (provide site, relationship, and age): Patient s signature: Date: AGE AT DIAGNOSIS FOR OFFICE USE ONLY Patient is appropriate for further risk assessment and/or genetic testing Information given to patient to review Follow-up appointment scheduled on Patient offered genetic testing: Accepted OR Declined HCP Signature:

11 HOW DID YOU HEAR ABOUT US? Thank you for choosing our office as your health care provider. Please take a moment and let us know more about why you chose our practice. This allows us to advertise most effectively and/or thank those that refer us. PLEASE CHECK ANY BOX THAT APPLIES (you can choose multiple options): MEDIA: Radio Yellow Pages Newspaper Internet WORD OF MOUTH: Insurance Doctor Friend WHOM MAY WE THANK FOR YOUR REFERRAL (if applicable)? Name: Phone: Company: N. Knoxville Ave, Suite 114, Peoria, IL (309)