Welcome to Providence Medical Group-OB/GYN Health Center. Dear Patient,

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Providence Medical Group OB-GYN HEALTH CENTER 940 Royal Ave., Suite 350 Medford, OR 97504 Tel: 541-732-7460 Fax: 541-732-7461 Providence Medical Group OB-GYN (CENTRAL POINT LOCATION) 870 S. Front St., Suite 200 Central Point, OR 97502 Tel: 541-664-3346 Fax: 541-664-6051 Maria Cordeiro, M.D. Shannon Fife, D.O. Nancy L. Hagloch, M.D. Karen R. Kronman, M.D. Alan G. Palamara, M.D. Lanita C. Witt, M.D. Amy Zastrow, M.D. Paula Daystar, W.H.C.N.P. Linda Osborne, C.N.M. Nancy Spector, W.H.C.N.P. Nancy Seulean, C.N.M. Welcome to Providence Medical Group-OB/GYN Health Center. Dear Patient, We look forward to seeing you in our clinic for your ongoing women s health care. Please review this information to be sure we have scheduled you for the appropriate visit that will meet your medical needs under Medicare. According to Medicare guidelines, any concerns that are not gynecologic in nature need to be addressed with your primary care provider. If you are at high risk for cancer, Medicare will cover a pelvic exam and breast exam every 12 months. Please see insert or visit www.medicare.gov for complete information. Please make sure that there is an interval of 24 months plus one day since your last pelvic and breast exam, (unless you are at high risk). If you need to discuss gynecologyrelated issues, please call our office and let the scheduler know so that an appointment of appropriate length may be scheduled. Please remember that your PCP must address all non gynecology-related issues. If you have further questions, please call our office at 541-732-7460.

Medicare Breast, Pelvic,Mammogram and Bone Density Screening FAQs Cervical and vaginal cancer screening (Pap test and pelvic exam) Medicare covers Pap tests and pelvic exams to check for cervical and vaginal cancers. As part of the pelvic exam, Medicare covers a clinical breast exam to check for breast cancer. How often is it covered? Medicare covers a Pap test and pelvic exam once every 24 months. However, if you are of childbearing age and have had an abnormal Pap test within the past 36 months, or if you are at high risk for cervical or vaginal cancer, Medicare will cover a Pap test and pelvic exam every 12 months. For whom? All women who are insured by Medicare. Your costs in the original Medicare plan? You pay nothing for the Pap lab test. For Pap test collection and pelvic and breast exams, you pay 20 percent of the Medicare-approved amount with no Part B deductible. What factors increase risk for cervical cancer? Your risk for cervical cancer increases if you: Have had an abnormal Pap test Have had cancer in the past Have been infected with the human papillomavirus (HPV) Began having sex before age 16 Have had many sexual partners Have a diet that is low in fruits and vegetables Are overweight or obese Had many full term pregnancies If your mother took DES (Diethylstilbestrol), a hormonal drug, when she was pregnant with you Breast cancer screening mammograms Breast cancer is the most common non-skin cancer in women and the second leading cause of cancer death in women in the United States. Every woman is at risk, and the risk increases with age. Breast cancer is often successfully treated when found early. Medicare covers screening mammograms and digital technologies for screening mammograms to check for breast cancer before you or a doctor may be able to feel it. How often is it covered? Once every 12 months. For whom? All women insured by Medicare, age 40 and older can get a screening mammogram every 12 months. Medicare also pays for one baseline mammogram for women covered by Medicare, between the ages of 35 and 39.

Your costs in the original Medicare plan? You pay 20 percent of the Medicare-approved amount with no Part B deductible. What factors increase risk for breast cancer? Your risk of developing breast cancer increases if you: Had breast cancer in the past Have a family history of breast cancer (mother, sister, daughter, or two or more close relatives who have had breast cancer) Had your first baby after age 30 Have never had a baby Used hormone replacement therapy for a long period of time after menopause Have two or more alcoholic drinks every day Are overweight or obese, especially if you gained weight during adulthood Don't exercise Are of eastern European Jewish descent (Ashkenazi) Risk for breast cancer increases with age. It is important to continue with screening, even if you were screened before you entered Medicare.

Providence Medical Group-OB/GYN Health Center confidential health history Please fill out these forms and bring them with you to your appointment. Name: Date: Date of birth: Age: Referring doctor: Occupation: Marital/relationship status: How long? How did you hear about us? Website/Internet Yellow Pages Postcard/mailer Friend/family member (name) Other Reason for visit: (problems to be addressed) Current medications: (Prescriptions, over-the-counter medications, supplements and vitamins) Tobacco use and history: Alcohol Use: Recreational Drug Use: Allergies: (medication, latex, or severe food allergies) Cycle history: Last period date: Regular Irregular No Periods Menopause Number of days between periods Length of period Problems/pain Quantity of flow: Light Moderate Heavy Spotting between periods Pap history: Last Pap date: Results: HPV Test Date: Results: History of abnormal Pap Treatment: Pregnancy history: Total number of pregnancies Deliveries Pre-term births Miscarriages: abortion: C-sections: Ectopic pregnancies

Number of living children: Adopted Stepchildren Weight of largest baby Sexual history: Currently sexually active: Age at first intercourse: Number of current partners Sex with: men women both Total number of partners: History of STDs or possible exposure to STDs Contraception: None needed Trying for pregnancy Previous methods of contraception: Problems with contraception History of: Emotional abuse Physical abuse Sexual abuse Medical history: Have you ever been diagnosed with or treated for problems related to: (explain) Eyes Corrective lenses Cataracts Glaucoma Ears Nose Throat Sinus Hay fever Heart disease Hypertension Murmurs Rheumatic fever Lung disease Asthma Pneumonia Stomach Intestinal Liver disorders GERD Hepatitis Ulcers Kidney disease Bladder disease Frequent bladder Infections Incontinence Muscle Bone disease Fractures Arthritis Skin problems Tattoos Piercing Brain Nerve disease Headaches Psychiatric problems Mental illness Eating disorders Diabetes Thyroid disease Anemia Blood clots Blood transfusions Gynecology problems: Menstruation Breast Vagina Uterus Ovaries Infertility Menopause Cancer Surgical history: Please list surgeries and/or hospitalizations

Family history: Include parents, grandparents, aunts, uncles, siblings & children Birth defects: Breast cancer: Ovarian cancer: Uterine cancer: Colon cancer: Heart disease: Hypertension: Diabetes: High cholesterol Osteoporosis: Bleeding: Blood clots: Mental retardation: Alzheimer s: Suicide: Mental illness: Alcohol or drug problems: Are you of eastern European (Ashkenazi )Jewish decent?

Name Please complete and bring these forms with you to your appointment. Review of symptoms: Are you currently experiencing problems with: General well being: Fever/chills Fatigue Weight loss ENT: Vision loss Discharge or pain Earache Runny nose or sore throat Dental problems Cardiovascular: Chest pain Irregular heartbeat Swelling of lower legs Respiratory: Cough Wheeze Shortness of breath Gastrointestinal: Nausea Vomiting Constipation Diarrhea Reflux Bleeding Genitourinary: Vaginal discharge, odor or itching Urinary incontinence Urinary pain or frequency Abnormal vaginal bleeding or spotting Pain or bleeding with intercourse Breast lumps, pain or discharge Concerns about sexual life or functioning Musculoskeletal: Joint pain Stiffness Arthritis Skin: Rash Itching Dryness New moles Sores Neurological: Headaches Numbness Weakness Dizziness/vertigo Psychiatric: Depression Anxiety Memory loss Insomnia Endocrine: Heat/cold intolerance Thirst Hair loss/growth Hot flashes Weight change Hematology/lymphatic: Severe bruising Easy bruising Enlarged lymph glands Allergic/immunological: Seasonal allergies Persistent infections Other: Health maintenance: Please date immunizations/tests/exams since your last visit: Immunizations: Flu Tetanus TDAP Pneumonia HPV Meningococcal Rubella MMR Varicella Shingles Hepatitis A B STD Screening HIV GC/chlamydia Mammogram Bone density Sigmoid/colonoscopy

Cholesterol screen Thyroid Diabetes screen Eye exam Dental exam Skin exam Other information your provider should be aware of:

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