ARTHRITIS & RHEUMATOLOGY OF GA, PC

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ARTHRITIS & RHEUMATOLOGY OF GA, PC GARY MYERSON, MD PAUL SUTEJ, MD PAULA TANASA, MD ANNA ADAMS, PA-C CASHELLE ROSE, PA-C NEW PATIENT REGISTRATION FORM (Please Print) PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Is this your legal name? If not, what is your legal name? (Former name): Birth date: Age: Sex: Yes No / / M F Street address: Social Security no.: Home phone no.: ( ) P.O. Box: City: State: ZIP Code: Occupation: Employer: Employer phone no.: ( ) Referred to clinic by (please check one box): Dr. Insurance Plan Hospital INSURANCE INFORMATION (Please give your insurance card to every visit) Person responsible for bill: Birth date: Address (if different): Home phone no.: / / ( ) Occupation: Employer: Employer address: Employer phone no.: ( ) Is this patient covered by insurance? Yes No Please indicate primary insurance BCBS UHC Aetna [Insurance] [Insurance] [Insurance] [Insurance] [Insurance] Medicare Other Subscriber s name: Subscriber s S.S. no.: Birth date: Group no.: Policy no.: Co-payment: / / $ Patient s relationship to subscriber: Self Spouse Child Other Name of secondary insurance (if applicable): Subscriber s name: Group no.: Policy no.: IN CASE OF EMERGENCY Name of local friend or relative (not living at same address): Relationship to patient: Home phone no.: Work phone no.: ( ) ( ) Authorization to Treat: I consent to examination, treatment and procedures which may be performed during my office visits including emergency treatment considered necessary by the physician and/or his designated provider. Assignment of Insurance: I hereby assign payment directly to Arthritis and Rheumatology of GA, P.C. for services covered by insurance or other health benefit plans. Authorization for Release of Information: I authorize ARG to release to my insurance carrier and its designated agents any medical information, including information related to psychiatric care, drug and alcohol abuse, and HIV/AIDS, necessary to process any healthcare related review or quality assurance activities. I also authorize the release of medical information to other healthcare providers who provide consultative services regarding my healthcare. This authorization remains in effect until revoked by me in writing. I agree that a photocopy of the same is as valid as the original. Patient/Guardian signature Date

Patient Contacts I/We authorize this medical practice to leave messages or discuss my PHI with the names listed below: (Include name and relationship) Phone: Phone: Primary Care Physician: Phone: Referring Physician: Phone: Additional Physician: Phone: Additional Physician: Phone: Privacy Policies and Office Policies I agree to the Privacy Policies (HIPPA) and Office Policies of Arthritis and Rheumatology of GA. I understand that a full copy of both the Privacy Practices and Office Policies are available to me at the office and at our website www.argmd.net. Patient Signature: Date: Pharmacy Name Phone Number and Fax Address Store Number Email Address Retail Pharmacy Specialty Pharmacy ARG Prescription Policy: Medications prescribed by Arthritis and Rheumatology of GA, P.C. must be taken only in accordance with the instructions and dosage as prescribed by your physician. Only designated annual patients will receive a full one year refill amount of their medication. Otherwise, medication refills are given at each office visit. If your medication requires a prior authorization, your pharmacy must contact our office. The prior authorization process can require up to two weeks to complete. You may always choose to pay by cash while you are waiting for the medication to be approved. Multiple calls to our office will not speed up this process, but we understand the frustration this often places on many of our patients. Please understand that our office is open Monday Thursday, each week from 7:00 am until 4:00 pm, and Closed on Friday. Our physicians will no longer call in refills after hours, over the weekend, or planned holidays. Emergency after hour calls are NOT intended for refill requests. Please plan accordingly. Patient Signature: Date:

Patient Questionnaire: Please check all involved; complete to the best of your ability. Red Measles COPD High Blood Pressure German Measles Tuberculosis Gastrointestinal Problems Mumps Liver Disease Chickenpox Diabetes Neurologic Disorders Polio Cancer Emotional Disorders Rheumatic Fever Skin Disease Pneumonia Kidney/Urinary problems Arthritis Asthma Heart Disease Connective Tissue Diseases Thyroid Disease Blood Disorders Comments: (Year, complications, other): Immunizations (Approximate date if known): Small Pox: / / Hepatitis B: / / Polio: / / German Measles: / / Tetanus Booster: / / Pneumonia: / / Mumps: / / Flu: / / Other (Specify): / / PPD: / / Risk Factors: Sun Exposure: Frequently Occasionally Rarely Remote Seatbelt usage: 100% 75% 50% 0% Cigarettes: /day Cigars: /day Pipe(s): /day Alcohol: /day Caffeine Intake (coffee, tea, cola, Etc.): /day Drugs (Marijuana, other): How often do you exercise per week? Types of exercise Family History/Illness: List age, state of health, (if deceased, include cause of death): Father: Mother: Sibling(s): Children (Male/Female)

Please Note the Relationship (Mother, Father, Etc.): Diabetes High Blood Pressure Heart Disease Kidney Disease Stroke Cancer Asthma Thyroid Disease Migraine Psoriasis Tuberculosis Arthritis Venereal Disease Double Jointed Hardening of the Arteries Connective Tissue Disease Review of Symptoms (Please check all that apply): General: Weakness Fever Chills Night Sweats Fatigue: Morning / Afternoon / Evening Weight Changes: More / Less Appetite Changes: More / Less Eyes, Ears, Nose, Throat (EENT): Ears: Difficulty hearing Tinnitus (ringing) Nose: Bleeding Running Post nasal drip Hay Fever Stuffiness Sneezing Sinus trouble Throat: Sore throat Hoarseness Dry mouth Throat pain Dental trouble Bleeding gum Respiratory: Shortness of Breath: At Rest / At Exertion Cough: Dry Wet Pleurisy Wheezing Bloody Chest Pain Asthma

Cardiovascular: Chest Pain: Tightness Squeezing Pressure Shortness of breath lying down Need to sit up to breathe Heart: Murmur Pericarditis Irregular: Racing / Palpitations Legs: Varicose Veins Pain at rest Pain with exertion Color Change: Blue/ Red/ White Breasts: Fibrocystic Disease Lumps Pain Discharge Gastrointestinal: Nausea Vomiting Heartburn Food intolerance Need for antacids/ppi's Gastritis GERD Ulcers Diarrhea Constipation Change in bowel habit Abdominal pain Diverticular disease Blood in stools Hemorrhoids Colitis Urinary: Burning Urgency Urinary tract infections Difficulty starting /stopping Discharge Kidney stones Interstitial cystitis Frequency: Day / Night Genito-Reproductive (Male): History of venereal disease Discharge from penis Rash on penis Testicular pain/lump Decrease in testicular size Decrease in sexual desire Decreased ability to achieve erection Genito-Reproductive (Female): Menstrual Period Flow: Heavy Normal Light Bleeding between cycle: Age of onset: Days between Period: Duration: Date of your last normal period: / / Menopause onset: Hot flashes Hormone Replacement Therapy Abnormal Vaginal Discharge History of Venereal Disease Genital Ulcers Pain during intercourse

Obstetrical: Please indicate the number for the following: Pregnancies Full Term Premature Miscarriages Stillborn (check all that apply) Complications: Preeclampsia Toxemia Severe hemorrhage Other(s): Endocrine: Thyroid Gland: Goiter Hyperthyroidism (overactive) Change in body hair (face, underarms, or pubic) Neurologic/Psychiatric: Hypothyroidism (underactive) Hashimotos Thyroiditis Diabetes Type I or II Increased thirst Heat/Cold intolerance Anxiety Depression Nervousness Sleep Difficulty Falling Asleep Frequent Awakening Early morning awakening Difficulty with memory (Past/Present) Difficulty with thinking/problem Solving Headaches/Migraines/Other Blackouts Dizziness Tingling/Numbness/Burning (Location): Double Vision Visual Blurring Paralysis/Weakness of Limb Loss of Sensation Balance/Coordination Problem Skin: Dryness Eczema Itching Psoriasis (Or Family History) Rash Dandruff Hives Nail Changes Welts Change in Texture of the Hair Change of Finger Color in the Cold: Blue / White / Red Hair Loss Rashes Caused By Sunlight Change in Skin Color Skin Ulcers Musculoskeletal: Extremities: Heat Redness Swelling Pain Stiffness Deformities Double Jointed Scoliosis/Kyphosis Muscle pain/weakness Bursitis Tendonitis

Spine (Neck, Mid and Lower Back): Heat Redness Swelling Pain Stiffness Morning stiffness (how many minutes to improve and location): Does the change in weather cause stiffness? Bones: Previous Fractures: please indicate what area/and year: DXA Scans (Bone Density) and date: Previous Arthroplasty- (Joint Replacement): yes no Please indicate the Body Prosthesis (Body Joint) - location and year: Please list previous surgeries: PLEASE LIST ALL CURRENT MEDICATIONS TAKEN: Include all prescription and over the counter medicines. Medication / Food ALLERGIES and Symptoms: Completed By: DATE:

Arthritis and Rheumatology of Ga. P.C. Dr. Gary Myerson ~ Dr. Paul Sutej ~ Dr. Paula Tanasa Past Medication Failure/Usage Please check all that applies. Indicate any side effects or adverse events NSAIDs: non-steroidal anti-inflammatory drugs Celebrex (Celecoxib) Voltaren (Diclofenac) Arthrotec (Diclofenac with misoprostol) Lodine (Etodolac) Nalfon (Fenoprofen) Ansaid (Flurbiprofen) Ibuprofen (Advil, Motrin) Indocin (Indomethacin) Ketoprofen (Actron, Orudis, Oruvail) Mobic (Meloxicam) Relafen (Nabumetone) Naproxen (Naprosyn, Naprelan, Aleve) Daypro (Oxaprozin) Feldene (Piroxicam) Salsalate (Salsitab) Sulindac (Clinoril) DMARDs Hydroxychloroquine (Plaquenil) Leflunomide (Arava) Cyclosporine (Neoral) Sulfasalzine (Azulfidine) Methotrexate (Rheumatrex, Trexall) Azathioprine (Imuran) Cyclophosphamide (Cytoxan) Cimzia/Enbrel/Humira/Kineret /Simponi Actemra/Remicade/Rituxan/Orencia IV Anti-depression/Fibromyalgia/Anxiety Adapin (doxepin) Celexa (citalopram) Cymbalta (duloxetine) Effexor XR (venlafaxine) Elavil (amitriptyline) Lexapro (escitalopram) Paxil (paroxetine) Prozac (fluoxetine) Pristiq (desvenlafaxine) Viibryd (vilazodone) Wellbutrin (bupropion) Zoloft (sertraline) Sleeping aid/anxiety Ambien (Zolpidem) Oleptro (trazodone) Sonata (Zaleplon) Lunesta (Eszopiclone) Dalmane (Flurazepam) Restoril (Temazepam) Remeron (mirtazapine) Neurological/Fibromyalgia Lyrica (pregabalin) Neurontin (Gabapentin) Acid reflux/gerd Aciphex (rabeprazole) Dexilant (dexlansoprazole) Kapidex (dexlansoprazole) Nexium (esomeprazole) Pepcid( famotidine) Prevacid (lansoprazole) Prilosec (omeprazole) Protonix (pantoprazole) Tagamet (cimetidine) Zantac (ranitidine) Osteoporosis Actonel Oral (Risedronate) Atelvia Oral (Risedronate) Boniva Oral or IV (Ibandronate) Evista Oral (Raloxifene) Forteo SubQ (Teriparatide) Fosamax Oral (Alendronate) Prolia Inj (Denosumab) Reclast IV (Zoledronic acid) Muscle relaxants Flexeril (Cyclobenzaprine) OTHER Soma (Carisoprodol) Zanaflex (Tizanadine) Skelaxin (Metaxalone)

ARTHRITIS AND RHEUMATOLOGY OF GA, PC 980 JOHNSON FERRY RD NE, STE 220 ATLANTA, GA 30342 PHONE: 404.255.5956 FAX: 404.528.1858 Directions to Northside Hospital Doctors Centre: Directions Traveling East on I-285 Exit #26 at the Glenridge Connector and turn right at the foot onto Glenridge Drive. Merge into the left hand turn lane, and turn left at the light onto Johnson Ferry Road. The Doctors Centre is on your left after crossing the bridge and before the next intersection. Turn left into the Doctors Centre, the 960 Building is on the left and the 980 Building is on your right. Parking is immediately ahead in the garage. The current cost to park is $6.00. Directions Traveling West on I-285 Exit #28 at Peachtree-Dunwoody Road and turn left onto Peachtree Dunwoody Road. Turn right at the fourth traffic light onto Johnson Ferry Road, in front of Northside Hospital. Pass Northside Hospital on the right, Scottish Rite on your left. The Doctors Centre is on your right, passing through the next traffic light. Turn right into the Doctors Centre and drive straight ahead for the parking garage. The 980 Building is on your right as your drive in. The current cost to park is $6.00. Directions from GA 400 (North and South) Traveling North take exit 4A and turn left onto the Glenridge Connector. Turn right at the light onto Johnson Ferry Road. The Doctors Centre is on your left before the Hospital. Traveling South- Take exit #3 and turn left onto the Glenridge Connector. Turn right at the light onto Johnson Ferry Road and the Doctors Centre is ahead on your immediate left. The parking deck is immediately ahead in the garage and the current cost to park is $6.00. ***Please be aware it is $6.00 cash, check, or card to park within the parking deck. This is regulated by a third party and not under our control. Thank you for your understanding. ***

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