WELCOME TO UBMD FAMILY MEDICINE OF AMHERST. Thank you for selecting your Primary Care Physician with UBMD Family Medicine of Amherst.

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WELCOME TO UBMD FAMILY MEDICINE OF AMHERST Thank you for selecting your Primary Care Physician with UBMD Family Medicine of Amherst. Some things to do before your visit Please call your health insurance company and notify them of your new Primary Care Physician. Please complete the enclosed three forms and return them to us ASAP (by mail, fax, or drop it off). When we receive your completed forms, we will contact you to set up an appointment. Appointments for new patients are generally scheduled 4-6 weeks in advance, so please return these forms as soon as possible. 1. New Patient Health History form 2. HIPAA Contact form - please let us know how we can leave information for you (e.g., on your voice mail, with a family member) 3. Authorization for Release form allows us to obtain any and all records from your previous physician(s) or health care provider. Your first visit Please bring: 1. Your Current Insurance card 2. Your co-pay (if applicable). We accept Cash, Check, Visa, MasterCard & Discover 3. Any paperwork that the Doctor needs to complete. Please arrive 20 minutes prior to your scheduled appointment time so we can answer any questions you may have and to be sure we have all your personal and insurance information correctly entered. If you need to cancel your appointment for any reason, please allow a 24 hour notice. If you have any questions, please feel free to contact us at (716) 688-9641. Forms may be faxed to (716) 829-2447. WELCOME! UBFM_Amherst_Newpatientpacket.Doc, v8/20/13

NEW PATIENT HEALTH HISTORY Please take time to complete the following information for your medical chart. This information is treated with strict confidentiality and will help us obtain a comprehensive assessment of your health care needs. *Please address EVERY section* PATIENT NAME REASONS FOR YOUR VISIT (list current symptoms) 1. 3. BIRTH DATE / / TODAY S DATE / / 2. 4. PAST MEDICAL HISTORY Please list ALL Surgeries- Procedures- Hospitalizations ~ INCLUDE DATE~ Procedure/Reason/Diagnosis Date Procedure/Reason/Diagnosis Date NONE 5. 1. 6. 2. 7. 3. 8. 4. Please use a separate sheet of paper to list any others MEDICAL ILLNESSES OR CONDITIONS Conditions you now have or have had in the past Condition Onset Date Condition Onset Date Condition Onset Date NONE Migraine headaches Seizures or convulsions (Type ) Stroke Polio Glaucoma Cataracts Blindness Recurrent ear infections Deafness Hay fever, allergic nose Recurrent sinusitis Stomach or duodenal ulcer Hepatitis Cirrhosis Gall stones Colon or bowel trouble Dysentery or serious diarrhea Rectal trouble Hemorrhoids Urinary Incontinence Recurrent urinary infections Kidney stones Other kidney disease Arthritis Goiter Gonorrhea Syphilis or other STD HIV infection /AIDS Herpes infection Chicken pox Mumps Measles Skin problems Depression Emotional problems Nervous breakdown Anxiety Asthma Chronic bronchitis Emphysema Tuberculosis Heart murmur Heart attack Angina Enlarged heart Rheumatic fever High blood pressure Hiatal hernia/chronic heartburn Gout Broken bones- (Type ) Varicose veins Phlebitis or blood clots Bleeding problems Anemia Cancer (Type: ) Diabetes Overactive thyroid Underactive thyroid Other Women Menstrual difficulties (Type ) Abnormal PAP Ovarian cyst(s) Breast lump(s) Men Prostate trouble Erectile Dysfunction

Name Please check all conditions identified in your biological ( blood ) relatives FAMILY HISTORY PLEASE note which relatives are affected; if extended family i.e. aunt/cousin/grandparent, please notate whether maternal or paternal Condition Relation Condition Relation Condition Relation Migraine headaches Stomach or duodenal ulcer Sickle cell disease Seizures or convulsions (Type _) Stroke Glaucoma Allergies Asthma Emphysema Tuberculosis Heart trouble (Type ) High blood pressure Early heart disease Liver disease (Type ) Gall stones Colon or bowel trouble Kidney stones Other kidney disease Arthritis Gout Bleeding problems (Type ) Anemia Cancer, including leukemia (Type ) Diabetes Thyroid problems (Type ) Suicide Birth defects (Type ) Emotional or Psychological Condition (Type ) Other: Condition Relation (males under 55, females under 65) IMMEDIATE FAMILY HISTORY Please complete the following information on your biologic relatives IF DECEASED, PLEASE INCLUDE AGE AT TIME OF DEATH Family Members Living Deceased Age Sex Chronic Condition(s) - If deceased, Cause of Death Father Mother Brothers or Sisters: Spouse Children

Name SOCIAL / PERSONAL HISTORY Please complete the following information about yourself. Current occupation: Education completed: Grade: High School College: years, degree/major _ Post-graduate: Marital status: Single Married Separated Divorced Widowed Number of Children Married time(s): Personal habits: (please check all that apply) Currently use tobacco: Type: Cigarettes Cigars Pipe Smokeless tobacco Amount / day: Years: _ Former smoker: Amount / day: Years: _ Quit Date: Never smoked Consume alcohol: Y / N Type: Amount / day: Use recreational drugs: Y / N Type: Frequency: Consume caffeine: Y / N Beverage: Amount / day: Exercise regularly: Y / N Type: Frequency: Wear my seatbelt: Frequency (%): _ IMMUNIZATIONS & PREVENTIVE SERVICES Check all that apply and PROVIDE DATE received PLEASE NOTE: All patients under 18 must have vaccine records either attached or transferred by previous MD DATE/Yr. DATE/Yr. DATE/Yr. NONE Hepatitis A vaccines PAP smear Flu vaccine Zoster Vaccine Mammogram MMR TB skin test: Bone density test Tetanus Hearing test: PSA Pneumonia vaccine Eye exam Colonoscopy Hepatitis B vaccines Other Other

Name ALLERGIES Include drugs, foods, chemicals, insects, etc. IF NO KNOWN ALLERGIES PLEASE CHECK NONE ITEM TYPE OF REACTION NONE PHARMACY INFORMATION Local Pharmacy Name: Pharmacy Street Address: Please provide accurate pharmacy information so that we can fill/refill medications you may need. Pharmacy Phone #: Do you use a Mail Order Pharmacy? Y / N If yes, Name of Mail Order Pharmacy: MEDICATIONS Include all current medications including prescription and over-the-counter herbal/vitamins/supplements IF NOT ON ANY MEDICATIONS PLEASE CHECK NONE NAME OF MEDICATION DOSAGE HOW OFTEN IS IT TAKEN? REASON FOR MEDICATION PHYSICIAN PRESCRIBING THIS MEDICATION EX: Aspirin 81 MG Daily, Twice a day, Bedtime etc. Stroke Prevention Dr John Doe NONE

Name PATIENT DEMOGRAPHICS Patient Name Street Address City State Zip Social Security # Date of Birth Sex: M or F Preferred Phone # ( ) Alternate Phone # ( ) Email Address Primary Language If primary language is not English: Do you speak English? Y / N Previous Primary Physician (please include address) RACE ETHNICITY MARITAL STATUS African American Hispanic or Latino Single American Indian/Eskimo Not Hispanic or Latino Married Asian Divorced Caucasian Widowed American Indian, Alaska Native Native Hawaiian/other Pacific Islander EMERGENCY CONTACT Name Note: If Under 18, name of Responsible Parent/Guardian Relationship ~ Is this person listed on your HIPAA Contact Form? Y / N Primary phone # ( ) Secondary phone # ( ) INSURANCE Primary Insurance Name: Policy Holder: Relationship to Patient: Social Security #: -- Date of Birth: / / Member ID: Group #: Secondary Insurance Name: Policy Holder: Social Security #: -- Relationship to Patient: Date of Birth: / / Member ID: Group #: SIGNATURE Signature If completed by someone other than the patient: Your Name: Date Relationship: UBFM_Amherst_Newpatientpacket.Doc, 8/20/2013

HIPAA CONTACT FORM UB FAMILY MEDICINE OF AMHERST 850 Hopkins Rd (at Klein) Williamsville, NY 14221 UB FAMILY MEDICINE AT JEFFERSON 1315 Jefferson Avenue Buffalo, NY 14208 UB FAMILY MEDICINE AT SHERIDAN 2465 Sheridan Drive Tonawanda, NY 14150 UB FAMILY MEDICINE ADDICTIONS MEDICINE 1408 Sweet Home Road Amherst, NY 14228 Patient Name: RECEIPT OF NOTICE OF PRIVACY PRACTICES Date of Birth: / / I have received a copy of the UB Family Medicine, Inc. Notice of Privacy Practice. (also available at UBFAMMED.COM) Signature: Date: / / Patient refused and/or unable to sign Staff member signature: AUTHORIZATION TO RELEASE INFORMATION TO FAMILY AND/OR FRIENDS Name Relationship Primary Phone Secondary Phone AUTHORIZATION TO LEAVE MESSAGES From time to time it may be necessary to leave you a message concerning appointments, financial issues, or other protected health information (PHI). Please indicate how you prefer we leave a message for you: Phone Number May we leave a voice message? May we leave a message with another person answering this phone? Voice Mail on Preferred Phone Number - - Yes No Yes No Voice Mail on Alternate Phone Number - - Yes No Yes No May we send a message? Send through US Mail Yes No RESTRICTIONS TO RELEASE OF INFORMATION Please list any restrictions regarding information to be released: SIGNATURE Signature: Date: / / This authorization shall be in force and effect until revoked by the patient or representative signing the authorization. UBFM_Amherst_Newpatientpacket.Doc, v8/20/13

Please complete Name and address of doctor (or other health professional) to release this information (e.g., your previous primary doctor) Please complete Only if to Atty/Gov Please complete Only if not patient Please Sign/Date

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