Race Ethnicity Primary Language Marital Status. Insurance Telephone Policy Holder Last Name Policy Holder First Name

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1 1. Patient Information (Please include all information as shown on insurance card.) Patient s Last Patient s First Date of Birth: Gender SSN Street Address Street Address 2 Patient Registration City State Zip Code Race Ethnicity Primary Language Marital Status Home Telephone Emergency Contact Address Primary Care Physician Alternate Telephone Emergency Contact Telephone Physician To Be Seen: Referred By 2. Medical Insurance Policy Holder (Check if self and complete only Insurance Information.) Primary Insurance Company Policy Number Group Number Insurance Telephone Policy Holder Last Policy Holder First Relationship to Patient Policy Holder SSN Policy Holder Date of Birth Street Address Street Address 2 Employer Work Telephone City State Zip Code Home Telephone Secondary Insurance Company Policy Number Group Number Last First Date of Birth Insurance Telephone SSN Relationship to Patient 3. Responsible Party/Guarantor (Check if self and complete only Employment Information.) Last First Date of Birth Street Address Street Address 2 SSN Relationship to Patient City State Zip Code Home Telephone Employer Work Telephone Complete only if patient is a minor and information differs from above. Parent s Last Parent s First Street Address City State Zip Code 4. Assignment of Benefits/Consent for Treatment I do hereby assign all medical and/or surgical benefits to which I am entitled, including all government and private insurance plans to this office. This assignment will remain in effect until revoked by me in writing. I understand that I am responsible for all charges not paid by insurance. I authorize this office to release all information necessary to secure payment. I hereby voluntarily consent to treatment at this office and authorize such treatments, examinations, medications, anesthesia, surgical, operations and diagnostic procedure (including, but not limited to the use of lab and radiographic studies) as ordered by attending physicians. Signature of Patient/Legal Guardian: Date:

2 Patient Authorization for Use and Disclosure of Protected Health Information The information on this form is used to facilitate our communications to you as we strive to provide you with excellent service. The provision of this information is optional. Patient Information (please print clearly): Last First Middle Initial Date of Birth (Month/Day/Year) Street Address Apt. #/P.O. Box # (Please include complete mailing address) Medical Record #/Social Security# (optional) City State Zip Code Primary Contact Number If we cannot reach you at the telephone number listed above, WellStar may contact you (including leaving messages) regarding appointments or normal lab results at the following number(s): Business Number Cell Other I authorize the WellStar Medical Group to disclose Protected Health Information to the following persons: Spouse: Child(ren): Other: Information to be disclosed All Medical Information Laboratory Results All Billing/Account Information Authorization Statement: I understand that Protected Health Information (PHI) used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and no longer protected by Federal or State Law. I understand that I have the right to revoke this authorization at any time. I understand that in order to revoke this authorization, I must do so in writing and present my revocation to the WellStar location where I received care. I understand that the revocation will not apply to information that has already been used or disclosed in response to this authorization. I understand that WellStar cannot require me to sign this authorization as a condition of treatment unless the provision of health care by WellStar is solely for the purpose of creating PHI for disclosure to a third party legally authorized to receive such information. I understand that I will be given a copy of this authorization. Signature/Date:(date authorization signed by patient or Legal Guardian/Personal Representative) Month/Day/Year Print Patient or of Legal Guardian/Personal Representative Signature of Patient or Legal Guardian/Personal Representative Indicate relationship to patient (required) Expiration Date: This authorization is valid until written notice is provided to revoke this authorization.

3 Acknowledgment of Receipt of Notice of Privacy Practices for Protected Health Information I acknowledge that I have received a copy of WellStar Health System s Notice of Privacy Practices for protected health information on the date set forth below. Date of Receipt Patient Information (please print clearly): Last First Middle Initial Date of Birth (Month/Day/Year) Print Patient or Legal Guardian/Personal Representative Relationship to Patient Signature of Patient or Legal Guardian/Personal Representative Release and Assignment: The information I have given is correct to the best of my knowledge. I understand that it will be held in the strictest confidence, and it is my responsibility to inform the WellStar Medical Group of any changes in my address, phone number or insurance. I understand that I am financially responsible for any amounts not covered by my insurance. For use by WellStar Personnel Only (complete this section if patient acknowledgement is not received): An Acknowledgment of Receipt of Notice of Privacy Practices was not received because: Patient refused to sign Acknowledgment Unable to gain signed Acknowledgment due to communication/language or other barrier Patient was unable to sign Acknowledgment due to emergency treatment situation Other: Please indicate reason Signature of WellStar Representative: Date:

4 MEDICAL mstory Page 1 Your : Your Date of Birth: Today's Date: Why are you here today? Age: WellStar Northwest Women's Care Please list or circle problems you are having: Menopause Pelvic pain Birth Control Issues Abnormal bleeding Irregular periods Vaginal discharge Is this a new problem? Describe problems on the following lines. Menstrual History: Contraceptive History: Date of the Brst day of last period Present Method: Normal? (circle) Yes No Problems (circle) Yes No Age of first period: years Condom Use (circle) Yes No Cramping? (circle) None Mild Have you ever used? (circle) Moderate Severe Birth Control Pills I Nuva Ring I Ortho Evra Patch Usual length: days IUD: Mirena, Copper T380 (Paraguard) I have my period every days Diaphragm. Cervical Cap Number of pads/tampons per day: Implanon, Depo Provera, Bleeding between periods? (circle) Yes No Condoms, Spermicide. Reality Clots? Number? Size? Vasectomy, Tubal Ligation, Essure Soak thru protection: (describe) Sexually active (circle) Yes No Recentchanges? Ever had sex? (circle) Yes No # Lifetime partners Female partner Obstetrical history (Include all pregnancies; deliveries, C-section, miscarriage, abortion, ectopic pregnancy.) Yes No Date Duration Birth Weight Sex ComplicationslPresent Health GYN History: If Menopausal: Check/circle any that apply. Age at menopause: years Abnormal mammogram, breast mass, pain Any bleeding since menopause? Abnormal Pap smear, treatment (circle) Yes No DES exposure in mother's pregnancy Hormone use? (circle) Never At Present In Past Diabetes in Pregnancy Year Started Year Stopped Endometriosis, pelvic pain Type/dose of hormones: Genital herpes, yourself or partner Genital warts, yourself or partner Increased hair growth Pelvic Inflammatory Disease Circle any symptoms that you experience: Recurrent urinary infections/frequency/urgency Hot flashes Urine loss Sexual dysfunction, yourself or partner Mood swings Bleeding Sexual abuse/assault Vaginal Dryness Breast Pain STDs: Gonorrhea, Chlamydia Urinary leakage I Incomplete emptying / Urgency Premenstrual Syndrome (PMS) Reviewed

5 MEDICAL HISTORY Page 2 0 Your Medical History: Circle/Check any that apply List any names of doctors Allergies Arthritis/Osteoporosis Baby weighing more than 9 lbs, Blood clots/phlebitis Body jewelry Location Bowel problemslulcersldiarrhealconstipation Broken/fractured bone DepressionIPsychological Problems Diabetesffhyroid Disease EmphysemalAsthmalPneumonia Heart DiseaseIMitral Valve ProlapselHypertension Hepatitis/Jaundice/Gallbladder Disease mv Infection or exposure MigraineslHeadaches/Seizures Alcohol Use: oz. per week Street Drugs: Type: Tattoos # location Tobacco Use: per day for years stopped smoking years ago Refuse Blood Products for Religious Reasons Other Concerns: (circle and describe) Heart Lungs Kidney Joints Gastrointestinal Calcium intake/day servings dairy/day mg in multivitamin Calcium tablets each mg Total mglday Calcium Vitamin D intake/day min sunshine/day units vitamin D over the counter/day units prescription vit D ~week units vitamin D with calcium tabs/day Total vitamin D units/day Other Hospitalizations: (Include date, hospital reason for admission and doctor.) Allergies/Drug Reactions: (Describe reaction/include latex allergy) Your : Date of Birth: Your Family's Medical History: Circle/Check any that apply Anesthetic Problems Bleeding Problems Blood clots in legs or lungs Breast Cancer Colon Cancer Ovarian Cancer Diabetes Elevated Cholesterol Genetic Problems Heart DiseaselHeart Attack Hepatitis/Other liver disease High Blood Pressure Kidney Disease Lung Disease Osteoporosis/hip fracture Puberty/Growth Disorders Seizures Skin Cancer Stroke Thyroid Unknown/Adopted Other: WeliStar NorthwestWomen's Care Speci fy for these: Relationship/Age of diagnosis - example: mother/48 memother. f=father mgm=matemal grandmother mgfematernal grandfather maematernal aunt pgm=paternal grandmother s=sister mu=maternal uncle pa=paternal aunt puepatemal uncle pgf=paternal grandfather Prior Surgery: List type of surgery (Include- date, hospital and doctor.) Medications: Put a star by the ones we prescribe and indicate 3- or l-month prescription (Ex: Estrace 1 mg (3)). If you take more than 2 medications, type the list on your computer and bring to your office visits and carry a copy in your wallet. (Prescription/over the counterlherballnutritional supplements. Please include dose and schedule). Reviewed

6 I WellStar Northwest Women's Care MEDICAL HISTORY Page 3 Health Care Maintenance Your : Date of Birth: PLEASE COMPLETE EACH BOX BELOW (for example, cholesterol 2000 normal) Date/Results: Recommendations: Check If Available Desired: at NWWC Pap Yearly or per provider * Mammogram Baseline 35-40/Every 1-2 years Years/50 and yearly Screening for Sexually Transmitted Diseases such as Yearly under 25 or as needed * Chlamydia, Gonorrhea **HIV Screen, Syphilis screen, Hepatitis A, B and C screen As needed * Cholesterol/Lipid Profile Every 5 years, sooner if abnormal * Thyroid Blood Tests Every 5 years after 40 * Colonoscopy Screening at 50, then every 5-10 years if (Scope to examine colon for polyps/cancer) African-American 45 Bone Density Test Menopause or other risk factors QUS (heel ultrasound) Depo-Provera use * **DEXA (x-ray test hip and spine) Eating disorder Low calcium intake Those immunizations not available at WNWWC may be available at Pediatrician, Family Practice, Internal Medicine office or Health Department Immunizations: Diphtheria, Pertussis, Tetanus Every 10 years * Measles, Mumps, Rubella If born 1957 or later, 2 nd dose after childhood Hepatitis B, Hepatitis A Teens, Young Adults * Meningitis Teens, Young Adults HPV (Gardasil) Teens, Young Adults under 27 years * Pneumovax 65 and older every 5 years Zostovax (Shingles Vaccine) 60 and older **Please check with your insurance company before your visit to see if they cover these particular tests. They may be less expensive at Any Lab or the Health Department. Who is your internist/family physician? Would you like a referral? No Yes (Please provide us with a list of doctors on your plan) Did you know? * Condoms save lives! People who exercise live longer. You are what you eat. We recommend a low fat, lower carbohydrate diet. Sunscreen use helps prevent skin cancer. Seat belts save lives! (Car accidents are the number 1 cause of death in females years of age.) Most girls/women do not get enough calcium. Most need mg a day! Smoking causes wrinkles, osteoporosis, low birth weight babies, emphysema and lung cancer. You can quit! We can help! No woman ever deserves to be battered. If you do not feel safe, we can help! Tell us!! I voluntarily give my consent for WellStar Northwest Women's care physicians (or any medical personnel under their supervision) to provide office gynecological care, including examinations, diagnostic testing (e.g., blood, urine, and ultrasound) and injections. This authorization remains in effect until I notify the office in writing that I no longer wish to receive care from this practice. I have received and reviewed a copy ofwnwwc, PC's HIPPA's notice of privacy practices. If under 18 years of age, complete: Signature ofpatient Date ~~cu~oili~pare~mkg~guarilianof~~~~~~~~~~~~~~~~~~,~orireexam~~~nandtre~e~ofmychild Signature Date THEB~TPHONENUMBERTOREACHME~EAVEAPR~TEMEDOCALME~AGE~:~~~~~~~~~~~~~~~~ PHARMACY # ~ Reviewed