PATIENT INFORMATION - ohsnj.com

1 Carol G. Simon Cancer Center Mountain Lakes Office Morristown Memorial Hospital 333 Route 46 West 100 Madison Avenue, Suite C3402. Mountain Lakes, NJ 07046 Morristown, NJ 07962. (P) (F) (P) (F) Welcome to our Practice: If you have not already done so, please complete the new PATIENT forms prior to your appointment. Please complete a detailed list of any and all medications you are taking as this is particularly important for the physician. Please remember to bring your insurance card(s) as well as a photo with you when you come in. IF YOUR insurance REQUIRES A REFERRAL PLEASE. OBTAIN A REFERRAL FROM YOUR PRIMARY CARE. PHYSICIAN PRIOR TO YOUR APPOINTMENT.

2 YOU WILL. NOT BE ABLE TO BE SEEN WITHOUT A REFERRAL IF. YOUR insurance REQUIRES ONE. PLEASE CHECK. WITH YOUR insurance CARRIER IF YOU ARE. UNCERTAIN IF YOUR POLICY REQUIRES ONE. ALSO, EACH PATIENT IS RESPONSIBLE FOR THEIR. DEDUCTIBLES, CO- insurance AND ANY OUT OF. POCKET COSTS. Thank you for your assistance, Oncology & Hematology Specialists, 1. Mountain Lakes Office Carol G. Simon Cancer Center 333 Route 46 West Morristown Memorial Hospital Mountain Lakes, NJ 07046 100 Madison Avenue, Suite C3402. (P) (F) Morristown, NJ 07962. (P) (F) PATIENT INFORMATION . Name (Last, First, MI) Social Security # Date of Birth Age Sex Marital Status Race Ethnic Origin Primary Language Home Phone Cell Phone Work Phone Street Address City State Zip Code Mailing Address (if Different than above) City State Zip Code E-mail Address Employement Status Employer Name Occupation Full Time Part-Time Retired Unemployed Student Employer Address City State Zip Code insurance INFORMATION .

3 Primary insurance Company Subscriber's Name Date of Birth Relationship Policy Number Group Number Secondary insurance Company Subscriber's Name Date of Birth Relationship Policy Number Group Number Prescription Card RX ID Number Rx BIN Number RX PCN Number RX Group Number **Fill Out Only if PATIENT is NOT the Subscriber**. Name of Subscriber OR PATIENT 's Spouse Social Security # Date of Birth Sex Relationship to PATIENT Street Address City State Zip Code Home Phone Employer Name and Address City State Zip Code Work Phone PHYSICIANS. Primary Care Physician Referring Physician EMERGENCY CONTACT INFORMATION . Contact Name (Last, First, MI) Relationship Primary Phone Number Secondary Phone Number PATIENT Release: I certify the INFORMATION that I have provided is correct.

4 I authorize the release of medical INFORMATION necessary to process insurance claims to insurance companies or their agencies (including Medicare), for purpose of filing and payment of medical claims. I authorize payment of medical benefits to the provider. I. ACKNOWLEDGE THAT INTEREST OR A FEE, AT THE PROVIDER'S CURRENT RATE, MAY BE CHARGED on all balances owing to the provider that are past due. I permit a copy of this release to be used in place of the original. PATIENT /Guardian Signature: Date: Original Date: Dates Revised: Health History Questionnaire All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

5 Name: Gender: Male Female Marital Status: Birth Date: Previous or Referring Doctor: Date of Last Physical Exam: Personal Health History Childhood Illness: Measles Polio Mumps Rubella Rheumatic Fever Chicken Pox Immunizations & Tetanus Pneumonia Influenza Dates Hepatitis Chicken Pox MMR (Measles, Mumps, Rubella). LIST ANY MEDICAL PROBLEMS THAT OTHER DOCTORS HAVE DIAGNOSED. Surgeries Year Reason Hospital Other Hospitalizations Year Reason Hospital 3. HAVE YOU EVER HAD A BLOOD TRANSFUSION? Yes No LIST YOUR PRESCRIBED DRUGS AND OVER THE COUNTER DRUGS, SUCH AS VITAMINS &. INHALERS (If you need more room please use a separate piece of paper). Name of the Drug Strength Frequency Taken ALLERGIES TO MEDICATIONS.

6 Name of the Drug Reaction You Had Health Habits & Personal Safety ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE OPTIONAL & WILL BE KEPT STRICTLY CONFIDENTIAL. Exercise Sedentary (No exercise). Mild exercises ( , climb stairs, walk 3 blocks, golf). Occasional vigorous exercise ( , work or recreation, less than 4x/week for 30 min.). Regular vigorous exercise ( , work or recreation 4x/week for 30 minutes). Diet Are you dieting? Yes No If yes, are you on a physician prescribed medical diet? Yes No # of meals you eat in an average day? Rank salt intake Hi Medium Low Rank fat intake Hi Medium Low Caffeine None Coffee Tea Cola Alcohol? Do you drink alcohol?

7 Yes No If Yes what kind? How many per week? Are you concerned about the amount you drink? Yes No Have you considered stopping? Yes No Have you ever experienced blackouts? Yes No 4. Are you prone to binge drinking? Yes No Do you drive after drinking? Yes No Tobacco Do you use tobacco? Yes No Cigarettes Chew - #/day Pipe - #/day Cigars - #/day # of years Or year quit Sex Are you sexually active? Yes No If yes, are you trying for a pregnancy? Yes No If not trying for a pregnancy list contraceptive or barrier method used: Any discomfort with intercourse? Yes No Illness related to the Human Immunodeficiency Virus (HIV), such as Yes No AIDS, has become a major public health problem.

8 Risk factors for this illness include intravenous drug use and unprotected sexual intercourse. Would you like to speak with your provider about your risk of this illness? Personal Safety Do you live alone? Yes No Do you have frequent falls? Yes No Do you have vision or hearing loss? Yes No Do you have an Advance Directive or Living Will? Yes No Would you like INFORMATION on the preparation of these? Yes No Physical and/or mental abuse have also become major public health Issues in this country. This often takes the form of verbally threatening behavior or actual physical or sexual abuse. Would you like to discuss this issue with your provider?

9 Yes No MENTAL HEALTH. Is stress a major problem for you? Yes No Do you feel depressed? Yes No Do you panic when stressed? Yes No Do you have problems with eating or your appetite? Yes No Do you cry frequently? Yes No Have you ever attempted suicide? Yes No Have you ever seriously thought about hurting yourself? Yes No Do you have trouble sleeping? Yes No Have you ever been to a counselor? Yes No 5. WOMEN ONLY. Age at onset of menstruation: Date of last menstruation: Period every days. Heavy periods, irregularity, spotting, pain, or discharge? Yes No Number of Pregnancies number of live births? Are you pregnant or breast-feeding? Yes No Have you had a D&C, hysterectomy, or Cesarean?

10 Yes No Any urinary tract, bladder, or kidney infections within the last year? Yes No Any blood in your urine? Yes No Any problems with control of urination? Yes No Any hot flashes or sweating at night? Yes No Do you have menstrual tension, pain, bloating, irritability, or other Yes No symptoms at or around time of period? MEN ONLY. Do you usually get up to urinate during the night Yes No If yes, # of times Do you feel pain or burning with urination? Yes No Any blood in your urine? Yes No Do you feel burning discharge from the penis? Yes No Has the force of your urination decreased? Yes No Have you had any kidney, bladder, or prostate infections within the last Yes No 12 months?