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PHYSICAL EXAM HISTORY NAME Chart# AGE D.O.B. TODAY S DATE: I. CHIEF COMPLAINT: II. HISTORY OF PRESENT ILLNESS: III. PAST MEDICAL HISTORY Check ( ) all that apply Peripheral Arterial Disease Diverticulosis Asthma Heart Disease Venous Insufficiency/Statis TB COPD Heart Failure Diabetic Peripheral Neuropathy Cataracts Anemia High Blood Pressure Thyroid Disorder Glaucoma Arthritis Diabetes Carotid Stenosis Blindness Dizziness Stroke Cholesterol Senile Dementia Gout Prostate Hearing Loss/Impairment Osteoporosis Allergies Eczema Macular Degeneration Blindness Incontinence Cancer Psoriasis Chronic Liver Disease Kidney Stones Chemo/Rad Ulcers IV. MEDICATIONS V. ALLERGIES Allergies to Anesthesia: Yes No VI. PAST SURGICAL HISTORY VII. PAST HOSPITALIZATIONS VIII. SOCIAL HISTORY: IX. REVIEW OF SYSTEMS = Normal Married? Yes /No /Other Heent Monogamous? Yes /No /Homosexual? Pulmonary # Children Residence Cardiac Live Alone? Yes /No Retired? Yes /No GI Occupation: GU Industrial Exposures: GYN Ever Smoked? Yes /No Packs/Day #Years MS Alcohol Drinker? Yes /No Drinks/Day Last PAP Last Mammo Drug User? Yes /No Colonoscopy Calcium Suppl. Dental Exam UTD Eye Exam UTD Dietary Hx Exercise Drives Car? Yes No Seatbelts used Flu Vaccine Last DT Pneumovax? X. FAMILY HISTORY Mom Dad Sibs YES NO Who in Family? Premature C.A.D. Hypertension Diabetes Mellitus Thyroid Disorder Breast Cancer Colon Cancer Other ASSISTIVE DEVICES: Wheelchair: Electric Scooter: Walker: Cane: Crutches: Eyeglasses: Hearing Aids: Dentures:

Suncoast Family Medical Associates Authorization for the Release of Information I hereby give my permission to (list physician/facility name and address): To release a copy of my Protected Health Information (PHI) to: Jeffrey S. Grove, D.O. Ty L. Tvedten, D.O. Samuel Pettina, D.O. N. Nicholas Engelman, D.O. Krista M. Keith, D.O. Eugene M. DiBetta, Jr., D.O. Enrique J. Urrutia, Jr., D.O. R.L. DaSo, D.C. I instruct the above named entity to produce the following information: (Check ONE only) Release entire record I would like specific records released: Please forward records to the following location: 12020 Seminole Blvd. Largo, FL 33778 (727) 588-9572 (727) 559-7181 fax Unless otherwise noted this authorization expires one year from date signed. My PHI is to be disclosed for: Continuation of care Other The undersigned is a patient of Suncoast Family Medical Associates or an authorized representative of the patient and requests that the above named facility to release any and all information which the named facility may possess in regard to the patient s examinations and treatments, including but not limited to, alcohol abuse or drug abuse information, HIV antibody testing information, psychiatric and/or psychological information, communicable disease information, or any other information related to the patient s total treatment, unless specified below, which may be a part of the medical records. I may revoke this authorization at any time by mailing or personally delivering a signed, written notice of revocation to the healthcare provider at which this authorization was executed. Such revocation will be effective upon receipt, except to the extent that the recipient has already taken action in reliance on the Authorization. I am entitled to a copy of this authorization upon my request. I may not be required to sign this Authorization as a condition to obtaining treatment or payment or my eligibility for benefits. The recipient of this protected health information is prohibited from re-disclosing the information unless the recipient obtains another authorization from me or unless the discloser is specifically required or permitted by law. Where permitted, the information I am requesting to be disclosed may sometimes by redisclosed by the recipient and may no longer be protected by law. I am entitled to notice if my protected health information is used for marketing and results in remuneration to the provider. I hereby acknowledge that I have read and fully understand the above statements as they apply to me. Print Patient Name: Signature of Patient: Signature of Guardian: Relationship: D.O.B.: Date: Date: Witness:

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