Revolutionizing Treatment * Restoring Hope * Improving Lives

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Revolutionizing Treatment * Restoring Hope * Improving Lives 6802 S. Olympia Ave., Suite G100 Tulsa, Oklahoma 74132 Phone: 918-949-6676 Fax: 918-949-6670 Please fill out the all paperwork and bring it along with your photo ID and medical insurance cards to your initial office visit. Thank You!

DATE: REFERRING PHYSICIAN: PRIMARY CARE PHYSICIAN: NAME: Last First MI Reason/Problem for Visit: Employer: Employer Phone: Retired: Year of Retirement: Email address (only used to send patient satisfaction survey): EMERGENCY CONTACTS: Name: Relationship: Phone: Cell: Name: Relationship: Phone: Relationship: Are you Claustrophobic: Name of Your Pharmacy: Phone: Fax: Are you an Organ Donor: Do you have an Advanced Directive or Living Will? If yes, date signed:

Please answer the following questions to the best of your ability. If you have a problem completing any section, please ask the doctor/nurse for an explanation. Have you ever been treated with radiation? Yes / No Date: Name & Location of the treating radiation facility: Do you have a pacemaker or defibrillator? Yes / No Have you been diagnosed with any chronic illness? (Diabetes, high blood pressure, etc.) Have you ever been admitted to a hospital for any of the following surgeries, other than for childbirth? (Circle ). Tonsillectomy Breast Biopsy Appendectomy Mastectomy Hysterectomy Colon/Rectal Surgery Gallbladder Prostate Bronchoscope Hemorrhoidectomy Lung Surgery List any other surgeries not mentioned above: Have you ever had any complications with anesthesia in the past? If yes, what issues did you experience? Do you have any allergies to medications, food or environment (i.e. dust)? Please list all current medications including the name, the dosage, and how many times a day you take it:

Have you every smoked? If yes, number of packs per day: How many years: Quit date: Do you consume alcohol? If yes, how much: How long? Has anyone blood related to you ever had any type of malignancy (cancer) including leukemia? If yes, list relationship below: Have you ever experienced any of the following? (Circle ) EARS EYES Difficulty Hearing Contacts/Glasses Deafness Double Vision Buzzing/Ringing in Ears Glaucoma Drainage from ear(s) Night Blindness Cataracts Pain in Eye(s) Blurred Vision; not corrected by glasses ENDOCRINE HEAD Night Sweats Headaches Enlarged Glands Tension (neck or under arms) Migraine Change in Scalp/Body hair Dizziness Poor Tolerance to heat/cold Thyroid Problems Abnormal Thirst Hot Flashes

GASTROINTESTINAL Liver Disease Yellow Jaundice Heartburn (Indigestion) Change in Bowel Habits Excessive Gas Weight Changes greater Nausea than 10 lbs in 6 months Vomiting Blood Trouble eating raw/greasy Diarrhea or spicy food Constipation Bloody Stool Bloody Stool Black/Tarry Stools Mucous in Stools Hemorrhoids Gallbladder Disease HEART Heart Murmur Swelling of feet or ankles Heart Attack Varicose Veins Anemia High Blood Pressure Shortness of Breath Blood Transfusions when lying flat Poor Circulation Pain/Cramps in Legs Fainting Spells Rheumatic Fever Pressure Attacks Chest Pain Palpitations MUSCULOSKELETAL NEUROLOGICAL Muscle Weakness in Tingling/Numbness arms or legs Loss of Consciousness Painful Joints Tremors/Shakes Swollen Joints Paralysis Pain/Aches in muscles Loss of Coordination Gout Balance Difficulties Arthritis Stroke Speech Difficulties

LUNG SINUSES Bronchitis Nose Bleeds Emphysema Sinusitis Tuberculosis Post Nasal Drip Pleurisy Difficulty Swallowing Wheezing Dentures Asthma Gum Disease Dental Cavities GENITOURINARY SKIN Kidney Infection Skin Cancer Bladder Infection Rash Pain or Burning List any other abnormalities: During Urination Blood in Urine Cloudy Urine Kidney Stone Gonorrhea Syphilis Difficulty Controlling Urine Getting up to Urinate at Night MEN ONLY Prostate Trouble Discharge from Penis Change in size of testicles Testicular Pain Difficulty having Erections Breast Lump

WOMEN ONLY Menstrual Cycle: Age of Onset Regular? Usual Duration Heavy Medium Light Any Cramps? Date of Last Menstrual Cycle: Birth Control Pill: Is Intercourse Painful? Number of Pregnancies: Number of Live Births: Number of Premature Births: Number of Still Births: Number of C-Sections: Number of Miscarriages: Any Complications? Are you Pregnant Now? Tubal Ligation? REVIEWED BY: DATE: TIME:

The information collected below is used strictly to evaluate marketing strategies. How did you initially hear about Oklahoma CyberKnife? (Mark One Only) Physician Physician Name: Television Channel: Internet What led you to our website? Billboard Location: Printed Ad Name of Publication: Family/Friend Name: News Story/Article Name of Publication: Mall Banner @ Woodland Hills What other places have you seen marketing related to Oklahoma CyberKnife? (mark all that apply) Television Billboard Internet Printed Ad Radio Family/Friend News Story/Article Other (elaborate) Mall Banner @ Woodland Hills Who is your primary care physician? Patient Name: Date:

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