PATIENT REGISTRATION

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PATIENT INFORMATION Last Name PATIENT REGISTRATION Please Print Clearly and Complete All Information Social Security # Middle Initial (Cell) (Home) What is your sex? (at birth) To complete the form below, check the number of family members in your home in the first column and your income in the column that best describes your situation. Income is used to determine Sliding Fee discount. Income reported FAMILY SIZE $ 25.00 A $ 35.00 B $ 45.00 C $ 55.00 D $ 65.00 E Full Charge F less than or equal to: less than or equal to: less than or equal to: less than or equal to: less than or equal to: Equal to or over: 1 $11,880 $14,850 $17,820 $20,849 $23,768 $23,769 Zip 2 $16,020 $20,025 $24,030 $28,115 $32,051 $32,052 3 $20,160 $25,200 $30,240 $35,381 $40,334 $40,335 4 $24,300 $30,375 $36,450 $42,647 $48,617 $48,618 5 $28,440 $35,550 $42,660 $49,912 $56,900 $56,901 6 $32,580 $40,725 $48,870 $57,178 $65,183 $65,184 7 $36,730 $45,913 $55,095 $64,461 $73,486 $73,487 8 $40,890 $51,113 $61,335 $71,762 $81,809 $81,810 INSURANCE INFORMATION / POLICY HOLDER INFORMATION PLEASE BRING A PHYSICAL COPY OF YOUR INSURANCE CARDS INSURANCE COMPANY Name POLICY HOLDER Last Name Who is the Policy Holder? Parent/Guardian Spouse Self Other Policy Holder Number Middle Initial Suffix Jr Other Sr Gender Policy ID # Group/Plan # Country SECONDARY INSURANCE / OTHER INSURANCE Who is the Policy Holder? Parent/Guardian Spouse Self Other INSURANCE COMPANY Name POLICY HOLDER Last Name Middle Suffix Initial Jr Sr Other Policy Holder Number Gender Policy ID # Group/Plan # Country EMERGENCY CONTACT Last Name Relationship Local Number -- Home Work Cell

Patient Name Page 2 I give my permission for a NH representative to contact me: Appointments Lab & Test Results Billing Announcements I authorize the release of information including the diagnosis, records, examination rendered to me and claims information. This Release of Information will remain in effect until terminated by me in writing. This information may be released to: Spouse Other Children Information is not to be released to anyone A copy of your Medical Records is available upon written request, via printed copy or electronically. 1.) Preferred Language English Spanish Arabic Chinese French German Italian Japanese Other Sign Language Unreported/ Refused to Report 2.) Do you feel you have a language barrier? 3.) 4.) 5.) Race (select all Black or African American White (Caucasian) Asian American Indian or Alaska Native Ethnicity Hispanic or Latino t Hispanic or Latino What is your Place of Birth? United s Other, please specify: Native Hawaiian Other Pacific Islander Unreported/Refused to Report 6.) Housing Status Are you homeless: Yes If yes: Shelter Doubling Up Street Transitional Housing 7.) Do you live in Public Housing: 8.) Agricultural Worker: Yes If you are an agricultural worker: Migrant Seasonal 9.) Are you a Veteran? FOR OFFICE USE ONLY: Documents Reviewed Pay Stub Tax ment SIGN HERE: W2 Letter of Support Etc. PATIENT OR RESPONSIBLE PARTY'S SIGNATURE NH WITNESS SIGNATURE Date Date

Patient Name Page 3 ABOUT YOU We would like you to tell us about your background so that we can review the treatment that all patients receive and make sure we provide the best possible care. Neighborhood Health maintains the privacy and security of your health information according to Federal regulations: HIPAA (Health Insurance Portability and Accountability Act) Allergies Have you ever had an allergic reaction? Medication Allergies: Food Allergies: Other Allergies (latex, bee stings, etc.): WHAT IS THE REASON FOR YOUR VISIT TODAY? What is your preferred Pharmacy? Pharmacy Name: /Location: #: _ In the past two weeks how often have you been bed by the following: t at all Some Most Every Day a. Little Interest or pleasure in doing things (Circle) 0 1 2 3 b. Feeling down, depressed or hopeless (Circle) 0 1 2 3 Do you often feel worried, anxious, stressed or irritable? ALCOHOL and DRUG SCREENING Have you felt the need to cut down on drinking or drug use? Have you ever felt annoyed by criticism of drinking or drug use? Have you had guilty feelings about drinking or drug use? Do you ever take a morning Eye Opener? HEALTH SCREENING / PREVENTATIVE (PLEASE INCLUDE THE DATE LAST PERFORMED) DATE LAST PERFORMED DATE LAST PERFORMED ROUTINE PHYSICAL FLU SHOT MAMMOGRAM TETANUS SHOT PROSTATE SCREENING PNEUMONIA SHOT BONE DENSITY SHINGLES VACCINE CHEST X-RAY HEPATITIS VACCINE EKG OTHER VACCINES CHOLESTEROL SCREENING DIABETES SCREENING PAP COLONOSCOPY who performed your PAP: who performed your colonoscopy: DENTAL EXAM extensive dental work? (teeth pulled, dentures, etc): _

Does YOUR IMMEDIATE FAMILY have any of the following? Birth Family history unknown M Alcoholism Blood clots/clotting Disorders Breast Colon Melanoma Other Cancers (list type) Diabetes Drug Dependency Heart Disease High Blood Pressure High Cholesterol Mental Illness Cancer Stroke Sudden Cardiac Arrest (under age 50) Other (Please explain) Parent Deceased Father Siblings Grandparents What is your work history? a. Current Occupation: b. Previous Occupation: c. Previous Occupation: What is your current gender identity? Transgender -to- Transgender -to- Neither Exclusively nor Other Decline to Answer What is your sexual orientation? Lesbian, gay Straight (not lesbian or gay) Bisexual Something else Don't know Decline to answer

Patient Name Page 5 YOUR CURRENT MEDICAL HISTORY Check any of the following YOU have ever had or are currently experiencing. Heart/Lungs Stomach/Bowel Hematology/Oncology STDs Asthma Celiac Disease Anemia Chlamydia Heart Disease Irritable Bowel Syndrome Bleeding Disorders Genital Herpes Heart Murmur Stomach/Duodenal Ulcers Blood Clots/Clotting Genital Warts High Blood Pressure Ulcerative Colitis/Crohn's Disorders Gonorrhea High Cholesterol Other Liver, Stomach, or Cancer HPV Pneumonia Bowel Disease Radiation Therapy Other STD Social History Endocrine Neurological OB/GYN History Do you drink alcohol? Do you smoke? Adrenal Disorders Diabetes Concussions Convulsions/Seizures Endometriosis Pregnancies Do you take recreational Polycystic Ovary Migraines/Severe Last Menstrual Period drugs? Syndrome (PCOS) Headaches Date Kidney Thyroid Disorder Multiple Sclerosis Could you be pregnant? Chronic Kidney or Mental Health Muscular Dystrophy Bladder Disease ADHD Stroke/TIA Are you breastfeeding? Incontinence Alcohol Abuse Activity Level Kidney Stones Anorexia (Eating Disorder) Would you say your activity level is: Surgical History Ears/Eyes/se/Throat Chronic Sinus Infections Eye Disorders ( than glasses or contacts) Hearing Loss Nasal Allergies/Hayfever Anxiety Disorder Bulimia (Eating Disorder) Depression Other Mental Health Problems Sedentary - Walk 1 hour, 2 times week or below Appendectomy Adenoidectomy Colon Surgery Ear Tubes Gallbladder Removal Hip Surgery Infectious Diseases Chickenpox/Varicella Hepatitis Type: HIV Infection Infectious Mononucleosis Malaria Mumps Tuberculosis Typhoid Fever Other History Previous Hospitalizations/ER Visits Skin Eczema Psoriasis Hives Orthopedics Arthritis Fractures/Broken Bones Moderate - Walk 1 hour, 3 times week Vigorous - Walk more than 1 hour, 3 times week L R Knee Surgery L R Hysterectomy Organ Transplant Ovarian Cyst Removal Prostate Surgery Splenectomy Tonsillectomy Weight Loss Surgery Other Prior Surgeries Health Literacy Please check your response to the questions below: a. How often do you have someone help you read medical materials? b. How often do you have a problem understanding the written materials about your medical condition? c. How often do you have a problem understanding what is told to you about your medical condition? d. How confident are you filliing out medical forms by yourself? 1 t at all 2 A little bit 3 Somewhat 4 Quite a bit 5 Extremely Do you have any disabilities or impairments? Yes, please specify Be prepared to inform the nurse, and any providers, of current medications (include birth control, acne, over the counter medications, vitamins, etc.) Choose ONE of the activities below that you would like to improve upon: Stay more physically active Take my medications Improve my food choices Reduce my stress Cut down on smoking July2016

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