Last name First name Middle Initial. Address City State Zip. Sex F M Date of Birth Social Security #

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1 Last name First name Middle Initial Address City State Zip Sex F M Date of Birth Social Security # Primary Phone # Secondary Phone # Other address Marital Status: Single Married Divorced Separated Widowed If married spouse s name Do we have permission to: Leave a message on your answering machine at home? Y/N Leave a message at your place of employment? Y/N Discuss your medical condition with any members of your household? Y/N If yes, whom? Relationship Emergency Contact: Name: Relationship: Phone Address City State Zip Primary Care Physician:

2 How did you hear about us? Doctor referral Family/Friends/Word of Mouth Website Television Radio The Heart of Jacksonville Clinic Magazine Newspaper/Magazine Advertisement Place of Worship Internet Search Mailer Social Media Yellow Pages Hospital Referral Community Event/Health Fair We are required to request the following information. The Federal Administrative Reporting Agency requests that we provide this information for statistical purposes only. Your participation is optional. Please take a moment to complete the following questions. Thank you. **If you choose not to participate please initial here: Race: Ethnicity: Preferred Language: American Indian Hispanic/Latino English Pacific Islander Not Hispanic or Latino Spanish Asian French African American/Black Arabic Caucasian/White Other

3 Medical History Date of last immunizations: Last Tetanus MM/YY Flu Shot MM/YY Pneumonia Vaccine MM/YY Shingles Vaccine MM/YY Date of last Preventative Test: Colonoscopy MM/YY Normal Y/N Mammogram MM/YY Normal Y/N PAP MM/YY Normal Y/N PSA MM/YY Normal Y/N Please check to the right of item: Aneurysm Diabetes Kidney Failure Rhemuatic Fever Anxiety Diarrhea Kidney Stones Seizures Artery Clot Dry Eyes Leg or Arm Shortness of Breath Angioplasty/Stent Emphysema Sleep Apnea Arthritis Fainting Spells Liver Disease Skin Rash Atrial Headache Leg Cramping Stomach Artery Angio/Stent Fibrillation/Flutter Asthma Heart Attack Loss of Hair Stomach Pain Blood or Clotting Heart Lung Clot Stroke/CVA Disorder Blockage Blood in Urine or Heartburn Narcolepsy Thyroid Disease Stool Bronchitis Heart Murmur Nephritis Tuberculosis Cancer Hemodialysis Night Sweats Urinary Issues type Carotid Stent Hepatitis Pain with Valvular Heart Disease urination Chest Pain Hiatal Hernia Palpitations Vision Loss or Double Vision Colitis High Blood Pancreatitis Please list and others below: Pressure Congestive High Peptic Ulcer Heart Failure Cholesterol Coronary Artery Disease HIV Peripheral Vascular Disease Coughing up Joint Swelling Pneumonia Blood Deperssion Kidney Artery Angio/Stent Prostate Issues Allergies Do you have any allergies to drugs, food latex or dye? Y/N If so please list below Allergy: Reaction:

4 Past Surgeries & Procedures Please to the right of the item: Aicd/Difibrillator Coronary Heart Valve Knee Tonsils/Adenoids Angioplasty Surgery Aortic Aneursym Coronary Artery Hernia Lap Band Valvuoplasty Repair Bypass Appendectomy Coronary Hemorrhoidectomy Mastectomy Vasectomy Revascularization Back EP study Hip Replacement Pacemaker Implant Please list any others: Cardiac Cath Gallbladder Homograft Prostate Replacement Cardiomyoplasty Gastric Bypass Hysterectomy RF Ablations Cardioverison Heart Transplant ICD Lead Extraction Sleep Apnea Surgery Family History Check all that apply to your parents or siblings Diagnosis Relationship YES DON T KNOW Arthritis Gout Asthma Cancer: What type: Mental Illness: What type: Diabetes Heart Disease Hypertension Kidney Disease Seizures Stroke Thyroid Disease Other: Smoking/Tobacco Use Y/N If yes, how many years Social History Packs per day Former Smoker/Tobacco Use Y/N If yes, how long ago Packs per day Alcohol Use Y/N If yes, how often: Monthly or less 2-4 times a month 2-3 times weekly 4 or more times weekly How many do you typically consume when drinking?

5 Substance Use Y/N If yes, How often: Yearly or less Monthly or less 2-4 times monthly 2-3 times weekly 4 or more times weekly What kind: Caffeinated Beverages Y/N If yes, how often: 1-2 cups daily 2-3 cups daily 3-4 cups daily 4 or more cups daily Diet Y/N If yes, what kind: Vegetarian Low fat Paleo Dairy free Vegan Other: Exercise Y/N If yes, how often: 1-2 times weekly 2-3 times weekly 4 or more times weekly What type: Current Medications: Please list any medications or vitamins and supplements Name: Dosage: How often: Please list you preferred pharmacy and location:

6 *** Our cardiovascular specialists have privileges at Baptist Medical Center, Baptist South, Memorial Hospital Jacksonville, Orange Park Medical Center, Specialty Hospital, Brooks Rehabilitation Hospital, St. Vincent's Medical Center Southside and Flagler Hospital. If you or your family members are admitted to these hospitals, please ask the ER doctors or admitting doctors for our doctors so we may provide you with the continuous excellent care you always enjoyed with our group. We are on call for our patients 24/7 at these locations. Our group provides you with board certified cardiologist and vascular specialist in several first coast area locations (see web). Please visit our web site for educational material on cardiac vascular medicine and the procedures we perform, learn about our research, and see photos of the first outpatient cardiac and vascular catheterization laboratory in the first coast. We strive to for excellence. Primary Insurance Company: Member Ins. ID# Group # Name of Insured if other than patient Relationship to Patient: Self Spouse Child Other Insured Date of Birth Social Security Secondary Insurance Company: Member Ins. ID# Group # Name of Insured if other than patient Relationship to Patient: Self Spouse Child Other Insured Date of Birth Social Security Print Name: Patient Signature: Date:

7 EPWORTH SLEEPINESS SCALE Pt: MR#: Rate your sleepiness as: 0 = No chance of dozing 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozing Example: If you are sitting and reading and feel that you have a high chance of dozing off, then put a #3 in the blank to the right. SITUATION Sitting and reading... CHANCE OF DOZING Watching TV. Sitting inactive in a public place (such as in a theater or in a meeting)... As a passenger in a car for an hour without a break.. Lying down to rest in the afternoon when circumstances permit... Sitting and talking to someone.. Sitting quietly after lunch without alcohol... In a car, while stopped for a few minutes in traffic... TOTAL (sum of above numbers)

8 Name DOB MRN# Please check ALL that apply to you: Do you snore? Have you been told you stop breathing during sleep? Do you wake up gasping for breath? Have you been told you often kick and move your legs during sleep? Are you excessively tired during the day? Do you have a history of hypertension (high blood pressure)? Do you feel tired even when you thought you had a good night of sleep? Have you been diagnosed with atrial fibrillation or congestive heart failure? Is your neck size greater than 17 inches (male) or greater than 16 inches (female)? Do you awaken unrefreshed? Do you have sensation of crawling feelings or discomfort in your legs when trying to sleep? Do you have trouble with falling asleep at night? Have you been told you talk or walk in your sleep? Do you suffer from occasional bedwetting? Have you been told that you act out your dreams? Do you feel paralyzed when falling asleep or waking up? Do you experience sudden weakness when laughing? Do you regularly require long naps during the day? Do you have uncontrollable daytime sleep attacks? Do you find yourself falling asleep during work or school? Have you noticed difficulty concentrating during the day? Do you find yourself falling asleep while driving? Have you noticed behavioral difficulties or difficulties at school? Do you suffer from teeth grinding during sleep?

9 Acknowledgement of Receipt of Privacy Notice We are required by law to offer you a copy of our Notice of Privacy Practices. To ensure that our records are accurate, please sign this form and return it to our receptionist to acknowledge that you have been offered a copy of our Notice. Assignment of Benefits I hereby assign to First Coast Cardiovascular Institute any insurance or other third-party benefits available for healthcare services provided to me. I understand that First Coast Cardiovascular Institute has the right to refuse or accept assignment of such benefits. If these benefits are not assigned to First Coast Cardiovascular Institute, I agree to forward the practice all health insurance and other third-party payments I receive for services rendered to me immediately upon receipt. I authorize the release of any medical or other information necessary to determine these benefits payable for the related equipment or services to the organization, the Health Care Financing Administration, my insurance carrier or other medical entity. A copy of this authorization will be sent to the Health Care Financing Administration, my insurance company or other entity if requested. The original will be kept on file by the organization. I understand that I am financially responsible to the organization for any charges not covered by health care benefits. It is my responsibility to notify the organization of any changes in my health care coverage. In some cases, exact insurance benefits cannot be determined until the insurance company receives the claim. I am responsible for the entire bill or balance of the bill as determined by the organization and/or my health care insurer if the submitted claims or any part of them are denied for payment. I understand that by signing this form I am accepting financial responsibility as explained above for all payment for products received. By signing this document, I also acknowledge that I have received a copy of the organizations Notice of Privacy Practices. This acknowledgement is required by the Health Insurance Portability and Accountability Act (HIPAA) to ensure that I have been made known of my privacy rights. Release of Records This letter certifies that I give permission to release copies of my personal medical records from First Coast Cardiovascular Institute, P.A. for treatment rendered at the office, to: Name of person signing (Print Name): Relationship to Insured: Patient Date of Birth: Signature of Insured or Parent/Guardian: Date:

10 Patient Care Team We want to be able to work closely with all of your doctors to have continuity of care and best serve you and your health needs, so please give us the name of each specialist you see. Specialty Name Phone# Fax # Allergist Cardiologist Endocrinologist ENT Gastroenterologist General Surgenon OB/GYN Hematologist Infectious Disease Nephrologist Neurologist Ophthalmologist Optometrist Pain Management Podiatrist Psychiatrist Pulmonologist Rheumatologist Urologist

11 jacksonvilleclinic.org firstcoastcardio.com No-Show and Cancellation Policy We understand situations arise in which you must cancel your appointment. Therefore, we require that you provide adequate notice which will allow another patient access to timely medical care. A NO SHOW is someone who misses an appointment without calling 24 hours in advance to cancel. Patients who No- Show three (3) or more times in a 12 month period, may be dismissed from the practice thus they will be denied any future appointments. Office and testing appointments which are cancelled with less than 24 hours notification or no notice will be subject to a $25.00 cancellation fee. Patients who do not show for their scheduled nuclear stress test or those who fail to notify the office at least 24 hours prior to their appointment will be subject to a $ cancellation fee. Patients who do not show for their scheduled sleep study or those who fail to notify the office 48 hours prior to their appointment will be subject to a $ cancellation fee. The cancellation and no show fees are the sole responsibility of the patient and must be paid in full before the patient s next appointment. We understand that unavoidable circumstances may cause you to cancel within 24 hours. Fees in this instance may be waived but only with management approval. Our practice firmly believes that good physician/patient relationship is based upon understanding and good communication. Questions about cancellation and no show fees should be directed to the Office Manager. We look forward to continuing our mission to provide the best healthcare in Northeast Florida and we thank you for choosing us as your healthcare partner. My signature below indicates that I have read and understand these policies. Patient Name (Please print) Patient Signature Date of Birth Date