WELCOME TO OUR OFFICE!! Thank you for selecting our practice. In order toprovide the best medical care and a great experience when you visit us please read on. If you haveany other questions, feel free to call us at (301)663-3836.

*************WHAT TO BRING WITHYOU*************

MEDICAL HISTORY FORM (if included in this packet) Filling this out at homewillgive you time to consider these questions instead of rushing to complete it while sitting inouroffice.

DRIVER’S LICENSE OR OTHER PICTURE ID This is to help prevent identitytheft

INSURANCE CARD AND COPAY The amount of the copay is usually printed onyourinsurance card. You will need to pay your copay when you arrive which you can pay withcash,check, orVisa/MasterCard

INSURANCE REFERRAL If required, your primary care doctor will provide this toyou.Check with your insurance company. Without it your insurance may not pay for yourvisit.

MEDICAL RECORDS Your other doctors will provide this for you when youask.

BRING THYROID ULTRASOUND OR SCAN FILMS to yourappointment.

If you are seeing one of our Endocrinologist, Dr. Hakim or Jinhui Yuan, PA-C we ask you to bringtheactual films for review. Please contact the radiology department where the test wasperformedto schedule a pick uptime.

PRESCRIPTIONS Bring the prescription bottles so your doctor knows exactly what youarecurrently taking and thedosage.

***********HELPFUL TIPS FROM OUROFFICE***********

RUNNING LATE? We understand that circumstances can sometimes prevent you from arrivingontime. If this happens, we will try our very best to accommodate you within the schedule. If weareunable to see you or you cannot wait, we will be happy to reschedule yourappointment.

CANCELLATION If you need to cancel or reschedule an appointment please call our office atleast24 hours before your appointment. Broken appointments represent a cost to us, and to otherpatientswho could have been seen in the time set aside for you. We reserve the right to charge for missedorlate-canceled appointments. Excessive abuse of scheduled appointments may result in dischargefromthepractice.

BLOOD PRESSURE CHECKS, ALLERGY INJECTIONS, FLU SHOTS You maycome

into our office without an appointment between 10 am and 12 pm or between 2 pm and 4 pm,onTuesdays, Wednesdays or Thursdays. There might be a wait but the nurse will see you as soonaspossible. If you cannot come during these times, please call our office so we can arrange a time thatismore convenient foryou.

PAYMENT If you have any questions about what insurances we accept, or about payment ofyourdeductible or copay please call our billing office at 301-663-3836 and select prompt2.

PRESCRIPTION REFILLS If you need to refill your medication that we have prescribed,callyour pharmacy. They will contact us for you to obtain the refillauthorization.

HOURS Our office is open Monday through Friday from 8:00 am to 5:00 pm. You can reach usbyphone between 8:30am and 4:00 pm. Our phones are off between 1:00 pm and 1:30 pm so our operatorscantakelunch.

ANY OTHER QUESTIONS,CALL (301)663-3836

******************DIRECTIONS*******************

Directions to Our Frederick Office from 270, 70 or 340, take 15 North towardsGettysburg. Take the Motter Avenue Exit. Bear to the right onto Opossumtown Pike. Go over thebridge. At the third light, turn right onto Thomas Johnson Drive. Go approximately 1 mile. Ouroffice is located of the left side at 65 Thomas Johnson Drive. We are in the second building inSuite C.

From Thurmont orEmmitsburg:Directly from route 15 (south) you will take theHayward Road Exit. At the yield sign bear to the right and continue on Hayward Road. Take yourfirst left onto Thomas Johnson Drive. Our office is located on the right side at 65 ThomasJohnson Drive. We are the second building in suiteC.

PATIENT INFORMATION FORM (PleasePrint)

PATIENTSNAME:

(LAST)(FIRST)(M.I.)

BIRTHDATE://AGE:SEX:SOCIALSECURITY#(SSN):

ADDRESS:

(STREET)(CITY)(STATE)(ZIPCODE)

HOMEPHONE:WORKPHONE:CELLPHONE:

EMAILADDRESS:

MARITALSTATUS:SINGLEMARRIEDDIVORCEDWIDOWEDPATIENTSEMPLOYER: POSITION:

EMPLOYERADDRESS:

IF PATIENT IS A MINOR, PARENT OR GUARDIAN’SNAME:

PERSON FINANCIALLY RESPONSIBLE FOR THISACCOUNT:

PRIMARY INSURANCE COMPANYNAME: SUBSCRIBER’SNAME:

SUBSCRIBER’S BIRTHDATE:

SUBSCRIBER’SSSN:

INSURANCE COMPANYADDRESS: COPAY: POLICYNUMBER: GROUPNUMBER:

SECONDARY INSURANCE COMPANYNAME: SUBSCRIBER’SNAME:

SUBSCRIBER’S BIRTHDATE:

SUBSCRIBER’SSSN:

INSURANCE COMPANYADDRESS: COPAY: POLICYNUMBER: GROUPNUMBER:

NEXT OFKIN:PHONENUMBER ADDRESS:

IN CASE OF EMERGENCYCONTACT:PHONENUMBER:

IF YOU ARE SEEING DR. HAKIM OR JINHUI YUAN, PA-C PLEASE LISTYOURPRIMARY CAREDR:
NAME: PHONENUMBER:

I AUTHORIZE THE ABOVE MEDICAL PRACTICE TO RELEASE ANY MEDICAL INFORMATION NECESSARY TO PROCESS MY CLAIMS.I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL FEES FROM SERVICES PROVIDED, INCLUDING THE BALANCEREMAINING AFTERPAYMENTOFPOSSIBLE INSURANCEBENEFITSANDANYCOSTSINCURREDBYTHEPHYSICIAN(S)INORDERTOCOLLECTSUCHFEES.

SIGNED:DATE:

PATIENT (OR PARENT’S SIGNATURE IF PATIENT IS AMINOR)

ENDOCRINE & METABOLIC HEALTH HISTORY (pleaseprint)

A. PERSONALINFORMATION
Name: / Gender:M /FToday’sDate:
Date ofBirth:Age: / Marital Status: □M□D□W□S
ReferringPhysician: / PrimaryPhysician:
OtherPhysicians:
Occupation:
B. REASON FORCONSULTATION
Please indicate the reason for your visit or your concerns orquestions:
1.
2.
C. GENERAL MEDICALINFORMATION
CONDITION / YES / Runsin Family / CONDITION / YES / Runsin Family
High BloodPressure: / □ / □ / LiverDisorder: / □ / □
HighCholesterol: / □ / □ / Gall BladderDisorder: / □ / □
HighTriglycerides: / □ / □ / Diverticulitis: / □ / □
DiabetesMellitus: / □ / □ / Other Abnormal/IntestinalDisorders: / □ / □
HeartAttack: / □ / □ / KidneyStones: / □ / □
Angina/CoronaryDisorder: / □ / □ / UrinaryInfection: / □ / □
Other HeartDisorders: / □ / □ / Other Kidney/BladderDisorders: / □ / □
Stroke/TIA: / □ / □ / Arthritis: / □ / □
Seizures/Convulsions/Epilepsy: / □ / □ / BackDisorder: / □ / □
MigraineHeadaches: / □ / □ / NeckDisorder: / □ / □
Other NeurologicalDisorders: / □ / □ / MenstrualIrregularities: / □ / □
Emphysema/Bronchitis: / □ / □ / Gout: / □ / □
Pneumonia: / □ / □ / Anemia: / □ / □
Asthma: / □ / □ / Cancer: / □ / □
Peptic UlcerDisease: / □ / □ / Phlebitis (Inflamed LegVeins): / □ / □
Other LungDisorders: / □ / □ / BreastProblems: / □ / □
Reflux Esophagitis/HiatalHernia: / □ / □ / ProstateProblems: / □ / □
Overweight/Obesity: / □ / □ / Glaucoma: / □ / □
SleepApnea: / □ / □ / Other EyeDisorders: / □ / □
AllergicDisorders: / □ / □ / Rashes or Other SkinDisorders: / □ / □
Please give any details if any conditions are marked“Yes”:

Name:

Date ofBirth:

ENDOCRINE CONDITIONS IN YOU OR YOURRELATIVES:
CONDITION / YES / Runsin Family / CONDITION / YES / Runsin Family
Pituitary: / □ / □ / Pancreas: / □ / □
Thyroid: / □ / □ / Ovaries: / □ / □
AdrenalGlands: / □ / □ / Testes: / □ / □
ParathyroidGlands: / □ / □
Please give any details if any conditions are marked“Yes”:

MedicationDoseFrequencyMedicationDoseFrequency

ThyroidSurgeryHysterectomy (UterusSurgery)BacksurgeryC-sectionAppendectomy (AppendixSurgery) Tonsillectomy

HerniasurgeryMastectomy (Breast Surgery) /BreastbiopsyGastric bypass/gastricsleeveJointsurgery Coronarybypass Gall BladderSurgery:Other:

Allergy to any drug(s) X-RayDyeFood

( ) tobacco:amount:( ) alcohol:amount:( ) regularexercise

( ) ionizing radiation exposure to head orneck( ) excessive intake of iodine-containingfoods

Name:

Date ofBirth:

General:( ) fatigue ( ) unintentional weight loss ( ) intentional weight loss ( ) weight gain ( )fever( ) chills ( ) excessive sweating ( ) excessive thirst ( ) feeling excessivelycold

( ) feeling excessively hot ( ) increase in appetite ( ) decrease inappetite( ) change in ring size ( ) change in shoesize

Neurological( ) depressedmood ( ) anxiety attacks ( ) excessive nervousness ( )irritability( ) blackout spells or loss of consciousness ( ) dizziness ( )forgetfulness

( ) difficulty concentrating ( ) headaches ( ) poor sleep ( ) sleep toomuch

Psychological:( ) numbness or tinglingin hands and/or feet ( ) tremors ( )seizures

Head/Neck:( ) visiblelumpin front of neck ( ) trouble swallowing ( ) painswallowing( ) persistent hoarseness ( ) voice change ( ) neck pain ( ) sinusproblems

( ) dry mouth ( ) sore throat ( ) swollen glands in neck ( ) neck fullness ( ) chokingsensation( ) pressure in theneck

Eyes:( ) bulgingeyes ( ) dry eyes ( ) eye irritation ( ) double vision ( ) tunnel vision( ) blurred vision ( ) loss of vision ( ) loss of peripheralvision

Skin:( ) dry skin ( ) itching ( ) dry or brittle hair ( ) hair loss or balding ( ) weak or crackingnails( ) easy bruising or bleeding ( ) yellowish skin ( )rash

( ) increased hair growth: ( ) face ( ) chest ( ) breast ( )abdomen

Heart/Lung:( ) palpitations ( ) swelling in feet or ankles ( ) chest pain ( ) shortness ofbreath( ) cough ( )wheezing

Gastro:( ) diarrhea ( ) constipation ( ) frequent bowel movements ( ) abdominal pain ( )nausea

( ) vomiting ( ) heartburn ( ) change in bowelmovements

Muscles/Joints:( ) muscleweakness ( ) muscle aches and pains ( ) swollen joints ( ) joint aches ( ) jointstiffness

G/U:( ) difficulty urinating ( ) excessive urination ( ) getting up to urinate atnight

Premenopause:( ) infrequent menses ( ) more frequent menses ( ) no menstrual cycle ( ) heavymenses( ) light menses ( ) hot flashes ( ) low sexual desire ( ) irregular menstrualcycle

( ) change in menstrualcycle

How old were you when you had your first menstrualcycle? What was the date of your last menstrualcycle? What method of contraception (if any) are youusing?

Postmenopause:( ) hot flashes ( ) low sexual desire ( ) vaginaldryness

Breasts:( ) breast tenderness ( ) fluid leakage from breast ( ) breastlump

( ) impotence ( ) low sexual desire ( ) difficulty with erections ( ) prostateproblems( ) testicular lumps ( ) pain intesticles

Updated 04/28/2016