Please Provide Accurate Phone Number for Contact Purposes.

UNC HEALTH CARE

Dear Patient:

Welcome to Anderson Medical Park, a division of Caldwell UNC Healthcare. Thank you for considering us as your healthcare provider. In order to allow our staff and practitioners to focus their energy on your healthcare needs, please take a few minutes to read and fully complete the enclosed packet of information.

Please be sure to bring your completed packet back to our office at least three days prior to your appointment. If for any reason you have not completed and returned this packet at that time, our office will contact you to have it brought in by the end of that business day. Failure to do so will result in your appointment being canceled and rescheduled for a later date.

As a courtesy, two days prior to your appointment, our office will send out a reminder call regarding your appointment date and time.

(Please provide accurate phone number for contact purposes.)

Anderson Medical Park... 270 Pine Mountain Rd., Hudson, NC 828-757-6330 Fax 828-757-6349 Blowing Rock Medical Park... 8439 Valley Blvd., Blowing Rock, NC 828-295-3116 Fax 828-295-4388 RiverCrest Medical Park... 160 River Bend Drive, Granite Falls, NC 828-757-5060 Fax 828-757-5068 Robbins Medical Park... 322 Mulberry Street, Lenoir, NC 828-757-6400 Fax 828-757-6424

Anderson Medical Park

270 Pine Mountain Road, Suite 4

Hudson, NC 28638

Sally Baird, FNP April Cotton, MD

John McMenemy, MD

Allison Sharpe, DO

Patient Information

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UNC

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HEALTH CARE

Full Name: / Address:
Birth Date: / City:
Age: / State: Zip:
Sex: o Male o Female / Primary Phone:
SSN#: / Work Phone:
Employment Status: / Mobile Phone:
Employer: / Secondary Phone:
Retirement Date (if applicable): / Email:
Marital Status: Please Check One
o Single
o Married
o Divorced
o Widowed
o Legally Separated
o Domestic Partner / Race: Please Check One
o American Indian or Alaskan Native
o Asian
o Black or African American
o Other Pacific Islander o Unknown/Other Race o White or Caucasian
Ethnicity: Please Check One
o Hispanic or Latino
o Non-Hispanic or Latino
o Unknown / Emergency Contact:
Emergency Number:
Relationship of Emergency Contact:
Preferred Language:
)" if Patient is a minor: Please Compl tt? this 'section
_ ..._
. Mothers Ne me: / father's ·Name
Mother's Birthdate: / Father's Birthdate:
Mother's Phone: / Father's Phon :
Is 1\/lother the Guarantor? y N / Is Father the Guarantor? y N

Insurance Information

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@CALDWELL

UNC HEALTH CARE

NEWPATlENT

MEDICAL HISTORY FORM

Full Name: _ _ _ Date: __

Birth Date:_ _ Age: _ _

H11i c ia n f r e!er en c e

ALLERGIES C NO ALLERGIES

ALLERGY / Ali;:ERGIC REACTION

MEDICATIONS

MEDICATIONS
{Please listALL) / DOSE
(Mg.,pill, etc.) / TIMES PER DAY
..

If you need more room to list medications, please write them on a blank sheet of paper with the required information

HEALTH MAINTENANCE SCREENING TEST HISTORY

CHOLESTEROL / Date: / Facility/Provider: / Abnormal / Result? / y / N
COLONOSCOPY /SIGMOID / Date: / Facility/Provider: / Abnormal / Result? / y / N
MAMMOGRAM / Date: / Facility/Provider: / Abnormal / Result? / y / N
PAP SMEAR / Date: / Fac[lity/Provider: / Abnormal / Result? / y / N
BONE DENSITY / Date: / Facility/Provider : / Abnormal / Result? / y / N

®CALDWELL

UNC HEALTH CARE

PERSONAL MEDJCAL HISTORY

..

DlSEASE/CONDITION CURRENT: PAS.T COMMENTS

Alcoholism/Drug Abuse Ast rn.a

Cancer (type:

Depression/Anxiety/Bipolar/Suicida I

Diabetes (type: }

mphysema. (COPD)

Heart Disease

1-!jgh·Eilood Pressure(hypertension)

' ·. . . ..

High Cholesterol Hypothytoidi.sm/Thyroid Disease Renal (kidney) Disease

Migraine Headaches Stroke

Other:

Other:

SURGERIES

TYPE (specify/ejt/right)
-.·.·..·· . / DATE / ·LO TION/FACILITY

WOMEN'S HEALTH HISTORY

Date of Last Menstrual Cycle: / Age of First Menstruation: Age of Menopause:
...
TotaiNurnber of Pregnancies: / ·--·
Numberof Live Births:
Pregnancy Complications:

,. '

®CALDWELL

UNC HEAL'I'H CARE

FAMILY MEDICAL HISTORY [] NO SIGNIFICANT FAMILY HISTORY IS KNOWN

Q)

·.!J.I

......

SOCIAL HISTORY

Occupation (or prior occupation): / 0 Retired 0 Unemployed 0 LOAD Disabled
-- --
Eil;iptoyer: . / ·•
Years qfEducation or '·Highest.t> gree:
If employed, do you work the night shift? y N N/A
MaritaiStatus(checkQne):OSingle 0 Partner 0 Married D r;>hiorced D\f\fide>wed 0 Other:
Do you have children? y N / If yes, how many?
Reli i()ll: .

,'·

OTHER HEALTH ISSUES

ItltCALDWELL

UNC HEALTH CARE

TOBACCO USE I Smoke Cigarettes? y N (If you never smoked, please move to Alcohol /Drug Use)
· . ·
Current: Packs/day #of Years I Past: Quit Date: Packs/day #of Years Other Tobacco (check one): 0 Pipe 0 Cigar 0 Snuff OChew
ALCOHOL/DRUG USE I Do you drink alcohol? y N / ..
0 ··. Beer 0 vyine. O ·Liquqr I #of Dril1ks/week:
Do you use marijuana or recreational drugs? y N / Have you ey r_used needles to inject drugs? YN
H ve you ever taken someone else's drugs? \'N
S ?<UAL fiiSTORY I Sexually involved currently? y N (If you are a virgin, please move to Excercise)
Sexual partner(s) is/are/have been: 0 Male 0 Female
Birth control method:O None Ocondom 0 Piii/Ring/Patch/lnj/IUD 0 Vasectomy
.. ..
EXERCISE I · Do you exercise regularly? y N (If you answered no, please rnove tc;, Sjeep)
What kind of exertise? / ..
Duration: How long (min.) : .. .. i-lowoften:
LE,EP I How many hours, on average, do you sleep at night (or during the day, if working night shift)?
·ottr' I How would you rate your diet? 0 GoodOFair 0 Poor I Wot..MVo li e advice on your diet? YN
SAFETY I Do you use a bike helmet? y N / Do you use seat belts consistently? y N
Working smoke detector in home? YN / If you have guns at home, are they locked up? YN
Is violence at home a concern for you? YN / Have you completed an Advance Directive for Health Care (ADHC), LivingWill, or Physical OrdersforlifeSustainingTherapy (POLST)? Y N

OTHER PROVIDERS/SPECIALISTS

SPECIALIST / NAME / LAST viSIT
Cardiology
Gastroenterologist (GI)
OB/GYN
Neurology
Pulmonary
Other:
Other:

ADDITIONAL INFORMATION

Have you traveled outside of the country in the last 30 days? y N / If yes, where?
Have you served in the military? y N / If yes, how long and whatbranth?
Were you deployed? y N / If yes, where?

I:CALD\JVELL

UNC HEALTH CARE

REVIEW OF SYSTElVlS: CHECK IF SIGNIFICANT PROBLEMS WITHIN THE LAST 3 MONTHS SKIN -EARS·. EYES

Yo No Rash Y O NO Loss/decrease of hearing Y O NO Blurry vision

Y O No Sores Y O NO · orainag from ars . · y o N.o prainage from eyes

y o NO Changes with a mole y o NO Ringing Y O NO Pain

rro NO Itchin /dryness ty o Nd· Earach lY. NQ ·VisiOtl ·!oss/changes

!Y o NO Hair and nail changes !Y o NO Flashing lights/dots

· ' '

J..U GS

HEART

·, . ._ ,·:_. ." •; ... ,·,....-..

,. . - .. . .

Y O NO Cough Y O NO Heart murmur/palpitations IY' o NO Pain in joints

yo 'NO Difficulty/painful breathing jY G ..NO . '· · t¥ o NO' · ·.Stiflne $

' ' . . . . .

YO No Coughing up blood Y O N 0 Swelling ty o NO Swollen joints

YD -No:

Wheezing

0 ND L g pain w en walklflg ty.[··J

-NO Eiack pain

'. . '.

GASTRO URINARY NEUROLOGIC

!Y'o NO Change in appetite Y O NO Frequency ty o NO Dizziness

rtC:I·;

·• NIJ 'Pro l m swallowing yp NCl ,Lirg ncy · ty'·El

NtJ Fainting

IY O NO Abdominal pain YO NO Burning or pain rv o NO Seizures

YO NO

Wheezing

Y[J Nd Blood in urine IYtJ _ NtJ

Weakness

!Y o NO Nausea/diarrhea Y O NO Incontinence Y O NO Numbness Y O NO Chahge in bowel habits YO NCJ Change .in urin ry streriSt [j Nd Tingling yo NO Rectal bleeding ty o NO Tremor

0 NiJ Constipation

·}

ENDOC INE HEAD

·. ,

. PSYCHIATRIC

Y O NO Heat/cold intolerance YO N 0 Headaches/migraines rr o NO Nervousness

YO No sweating yo NO Ne<;kpain IY O NO' .... .

Str'es·

0 NO Thirst Y O N 0 Head injury Y O NO Depression

Y O NO Change in appetite y o NO Memory loss

·BREAST VAGIN.AL PROSTATE

Y O NO Lump(s) Y O NO Discharge ty o NO Lump(s)

y [J N. , O...

Pain Y O NO Hot flashes y-q NO ain/pain with sex

Y O NO Discharge y o N 0 Change in periods Y O NO Lesions/sores

Y O NO

',

Tenderness

YO N ·D

Itching ()r dr)ines

y g NO

lo s of sex drive

y o NO Color changes rt O N 0 Pain with sex Y O NO Hernia

[Y O NO Loss of s x drive

0 NO Lesions/sores

List Other Problems Here:

llliCALDWELL

UNC HEALTH CARE

VACCJNA TION HISTORY- LIST DATE and LOCATION

. ,. ..

...

IllCALDWELL

UNC HEALTH CARE

321 Mulberry Street, SW ·Post Office Box 1890 ·Lenoir, North Carolina 29645 Phone: 828 ·757 ·5100

Off Campus Medicare/ Medicaid Outpatient Coinsurance Notice If you are a Medicare/Medicaid Patient:

Medicare/Medicaid regulations require us to provide you with a notice of your potential financial liability for the hOspital service(s} you will receive.

Since the exact type and extent of care needed is not known, we are required to advise you that, because the services(s) are furnished by a department of Caldwell Memorial Hospital, you will incur a coinsurance liability to the hospital that you would not incur if the services were furnished in an entity that is not hospital-based.

The coinsurance liability to the hospital is in addition to any Medicare/Medicaid coinsurance liability for physician/professional services provided in conjunction with the hospital services.

I have read the foregoing and understand that I will incur a liability to the hospital for Medicare/Medicaid coinsurance as permitted by law.

Signature of patient or authorized representative Date

inlJI\,JC

HEALTH CARE Patit:i:n Name __

Date of Birth _

Limited Release of Information to Family/Fniends for Physician Clinics

HIM# 1315s

I give my permission to my physician practice that is part of the UNC Health Care System to shar certain personal health information about me with the individuals listed below. These individuals wil only be given information about me that is related to their involvement in my care or payment for my care..1 understand that Iam not required to complete this form in order to obtain health care.

Name: Phone Number: Relationship: Talk to this person about (check each box that applies):

0 Any non-sensitive 2 information regarding my health care or payment for my health care.

OR

0 Only these things:

I

Name: Phone Number: Relationship: Talk to this person about (check each box that applies):

0 Any non-sensitive 2 information regarding my health care or payment for my health care.

OR

0 Only these things:

My appointments - scheduling reminders / My test results
My after visit summary (AVS) / My bills
Other:

If I change my mind about tbe people or tbe contact information I have listed in this form, I will complete a new form with such changes.

----,------DATE: _ TIME:____

p TIEN"r SlON.A TURE (or Authpriz.e4 Reple'$.en1alil' J

PRINTED NAME RELATIONSHIP (if not patient): ------

1  This form is not a substitute for a health care power of attorney or other formal designation of an individual authorized to make health care decisions for you if you are not able. If an individual listed above is your guardian or agent (under a power of attorney), or is otherwise authorized by Jaw to act on your behalf, your health care provider may share as much of your personal health information with that person as the law permits.

This form is not a substitute for a valid HIPAA compliant written authorization when it is required to release copies of medical and billing records or information.

2  Non-sensitive information excludes mental health, alcohol and substance abuse, I-UV and other communicable diseases, and genetic testing. This form is not considered sufficient autboll"ization to release sensitive information.

Chart Location: Consents

HDF5338 06109117

...·JCALDWELL

UNC HEALTH CARE

Anderson Medical Park

270 Pine Mtn. Road Ste 2

Hudson, NC 28638

AUTHORIZATION FORM- HIM #710-S

OFor all other record requests please send:

ATTN: Anderson Medical Park Phone: (828) 757-6330

Fax: (828) 757-6349

I authorize:

UNC Health Care System OR

I Other facility:

To use or disclose to:

Name of Person or Facility:

ANDERSON MEDICAL PARK

Address ) City I State I Zip

270 PINE MTN RD SUITE2 HUDSON NC 28638

Phone: I Fax: 1 Email: 828-757-6330 828-757-6349

The protected health information of:

Patient Name: I Date of Birth: I SS# (last 4):

Address I City I State I Zip Phone: I UNC Medical Record #

Dates of Service: ------

Put a CHECKMARK next to the specific documents that apply to your request·.

Clinic notes (outpatient) Operative I Procedure notes Progress Notes (inpatient) Emer_gency Dept. notes Providers Orders Radiolo gy reports

Urgent Care Center notes Nursin g notes ·P,a erin:nlling re.cords

History and Physical Consultations :'Eilnl'/Ctf (@giQ.g.support)

Discharge Summary_ Laboratory reports All'M:edichl .Records

Other (describe)

I

I understand that the information released may include sensitive information related to behavior and/or mental health, drugs and alcohol (including records of a program that provides alcohol or drug abuse diagnosis, treatment, or referral, as defined by federal law at 42 C.F.R. Part 2), HIV/AIDS and other communicable diseases, and genetic testing. This authorization does not include permission to release psychotherapy notes (defined as records from private, joint, group, or family counseling sessions that are separated from the rest of the patient's medical record). Release of psychotherapy notes requires a separate authorization.