Southwest Nephrology Associates_ L.L.P

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					                                           Southwest Nephrology Associates, L.L.P
                                                        Internal Medicine, Nephrology and Dialysis

Charles K. Crumb, M.D., P.A.
Carmelo C. Dichoso, M.D., P.A.
Robert H. Porter, M.D.
Marializa V. Bernardo, M.D., P.A.   Attached are Patient Information forms for our office. Please complete them
Caleb Chen, M.D., P.A.              and bring them with you to the appointment.
Amer A. Khan, M.D., P.A.
Charles S. Henry, M.D., P.A.
                                    In addition, we request that you also bring the following:

                                       1. Your insurance card, along with any referral forms and/or lab reports
                                          you may have been given by your referring doctor. Insurance co-
                                          payments are collected at the time of service and must be paid by
MAIN OFFICE:
7777 S.W. FREEWAY
                                          cash or check, Visa or MasterCard.
SUITE 304                              2. Driver’s License or other photo I.D.
HOUSTON, TEXAS 77074                   3. ALL MEDICATIONS YOU ARE CURRENTLY TAKING.
713-270-4545
FAX: 713-270-9197

                                    In the event you are unable to keep your appointment, we would appreciate
                                    notification as soon as possible.
WEST HOUSTON OFFICE:
12121 RICHMOND
SUITE 103                           If you have questions, or if we can be of additional assistance, please do not
HOUSTON, TEXAS 77082                hesitate to contact our office.
713-270-4545
FAX: 713-270-9197
                                    Sincerely,

                                    Southwest Nephrology Associates, L.L.P.
SUGAR LAND OFFICE:
16659 S.W. FREEWAY
PROFESSIONAL BLDG. II
SUITE 401
SUGAR LAND, TEXAS 77479
713-270-4545
FAX: 713-270-9197




RICHMOND OFFICE:
1601 SOUTH MAIN
OAK BEND PROF. BLDG.
SUITE 407
RICHMOND, TEXAS 77469
281-238-9600
713-270-4545
FAX: 713-270-9197




                                                                                                            Page 1 of 13
                       Financial Policy of Southwest Nephrology Associates, LLP

Thank you for considering Southwest Nephrology Associates, LLP, to provide your renal (kidney) care. Our main
concern is that you receive the best care possible. In order to prevent any misunderstandings and to serve you better,
we ask that all patients read our financial policy. If you choose Southwest Nephrology Associates for your renal care,
we will ask you to sign this policy at your first visit. If you have any questions or concerns about our policies, please do
not hesitate to ask.



    1.    As a courtesy, we will file your insurance if you are a member of an insurance plan with which we are
         contracted. If you are not able to provide us with a valid insurance card, you will be required to pay cash for
         your visit. If your insurance has changed since your last visit, please inform us before your visit, so that we
         may verify your coverage and benefits, then bring your new card when you come for your visit. Most
         insurance plans require that a claim be filed within 90 days of the date of service, so if we file with your
         previous insurance because you have not informed us of the changes, you will be responsible for any unpaid
         balance resulting from the filing delays. Please remember that all charges are your responsibility, whether or
         not your insurance pays.

    2. FIXED COPAYS WILL BE COLLECTED AT THE TIME OF YOUR VISIT. Inability to make payment at that time may
       require us to reschedule your visit. Deductibles, co-insurance, and non-covered services are also due at the
       time the service is provided. This includes Medicare deductibles and co-insurance, as it can be considered
       Medicare fraud to waive these amounts.

                                WE ACCEPT CASH, VISA, MASTERCARD, AND PERSONAL CHECKS.

    3. MEDICAL RECORDS will be shared with another physician at your written request at no charge to you. If you
       require a copy of your chart, you will be charged $25 for this service.

    4. MISSED APPOINTMENTS: If you are unable to make your appointment, we must have notice from you 24
       hours in advance. If you miss two appointments without adequate notice, you will be charged a “missed
       appointment fee” of $25.

    5. RETURNED CHECKS will incur at $30 fee. The amount of the check plus the fee must be paid within 10 days of
       notification by money order, cash, or credit card to prevent further action. If a second check is returned on
       your account, we will no longer be able to accept personal checks as payment.




                                                                                                                  Page 2 of 13
PATIENT INFORMATION: (PLEASE PRINT)

LAST NAME ____________________________ FIRST NAME_____________________ MI _____
SEX: _ MALE __ FEMALE       BIRTH DATE _____/ _____/ ________
ADDRESS:____________________________________________________ APT. #: ___________
CITY: ______________________________ STATE: _______ ZIP: ____________ COUNTY _______________
HOME PHONE: (______) ______-______________    SOCIAL SECURITY: _________-_______-__________
CELL PHONE: (______) ______-______________    EMAIL ADDRESS ______________________________
MARITAL STATUS: __ SINGLE      __MARRIED     __DIVORCED     __WIDOWED
PRIMARY LANGUAGE: __ ENGLISH __ SPANISH __OTHER           RELIGION: _________________________
EMPLOYER: __________________________________________ WORK PHONE: (______) ______-_________
ADDRESS:___________________________________________________________________________________
CITY:__________________________________ STATE:______________ ZIP: __________________________
EMPLOYMENT STATUS: __ FULL-TIME __ PART-TIME __ RETIRED OCCUPATION _______________


GUARANTOR INFORMATION:                 RELATIONSHIP TO PATIENT: ____________________________
LAST NAME ____________________________ FIRST NAME_____________________ MI _____
SEX: _ MALE __ FEMALE       BIRTH DATE _____/ _____/ ________
ADDRESS:____________________________________________________ APT. #: ___________
CITY: ______________________________ STATE: _______ ZIP: ____________ COUNTY _______________
HOME PHONE: (______) ______-______________    SOCIAL SECURITY: _________-_______-__________
MARITAL STATUS: __ SINGLE      __MARRIED     __DIVORCED     __WIDOWED
EMPLOYER: __________________________________________ WORK PHONE: (______) ______-_________
ADDRESS:___________________________________________________________________________________
CITY:__________________________________ STATE:______________ ZIP: __________________________
EMPLOYMENT STATUS: __ FULL-TIME __ PART-TIME __ RETIRED OCCUPATION _______________


INSURANCE / PAYMENT INFORMATION: (Circle one):       INSURANCE     CASH CHECK
PRIMARY
PLAN NAME: _______________________________________ NAME OF INSURED: ______________________
GROUP #: ______________________________ MEMBER ID / POLICY # _________________________________
INSURED’S RELATIONSHIP TO PATIENT ______________ MAIL CLAIM TO: __________________________
ADDRESS___________________________________________________ CITY ______________________________
STATE _____________________________ ZIP _________ PHONE # (_____) _______-_____________
SECONDARY
PLAN NAME: _______________________________________ NAME OF INSURED: ______________________
GROUP #: ______________________________ MEMBER ID / POLICY # _________________________________
INSURED’S RELATIONSHIP TO PATIENT ______________ MAIL CLAIM TO: __________________________
ADDRESS___________________________________________________ CITY ______________________________
STATE _____________________________ ZIP _________ PHONE # (_____) _______-_____________
                                                                                          Page 3 of 13
LEGAL NEXT OF KIN                      RELATIONSHIP TO PATIENT ____________________________
LAST NAME _____________________________ FIRST NAME __________________________________________
ADDRESS ____________________________________________________ APT. # _____________________
CITY _______________________________ STATE _________ ZIP _______________
HOME PHONE (_____) ________-_______________ WORK PHONE (_____) ________-_______________


EMERGENCY CONTACT                      RELATIONSHIP TO PATIENT ____________________________
LAST NAME _____________________________ FIRST NAME __________________________________________
ADDRESS ____________________________________________________ APT. # _____________________
CITY _______________________________ STATE _________ ZIP _______________
HOME PHONE (_____) ________-_______________ WORK PHONE (_____) ________-_______________


CLINICAL INFORMATION: THIS VISIT RELATED TO (Circle one) ACCIDENT ILLNESS PREGNANCY
IF ACCIDENT, DATE AND TIME OF ACCIDENT: __________________________ AT ______:______ AM / PM
IF ACCIDENT, LOCATION OF ACCIDENT: ________________________________________________________
PRIMARY CARE PHYSICIAN (PCP) OR FAMILY DOCTOR ___________________________________________
ADDRESS ___________________________________________________ PHONE (_____) _______-____________
IF APPLICABLE, THE NAME OF THE DOCTOR WHO REFERRED YOU ______________________________
ADDRESS ___________________________________________________ PHONE (_____) _______-____________
REASON FOR TODAY’S VISIT ____________________________________________________________________
________________________________________________________________________________________________


ASSIGNMENT OF BENEFITS:
I REQUEST THAT PAYMENT UNDER THE MEDICAL INSURANCE PROGRAM(S) ABOVE BE MADE TO MY
DOCTOR ON ANY MEDICAL SERVICES PROVIDED BY HIM/HER. I ALSO UNDERSTAND THAT I AM
RESPONSIBLE FOR THE PAYMENT FOR MEDICAL SERVICES THAT I RECEIVE AND AGREE TO PROMPT
PAYMENT OF DEDUCTIBLES, COPAYMENTS, AND OTHER ELIGIBLE AMOUNTS NOT COVERED BY THE
ABOVE INSURANCE PLAN(S).

I ALSO AUTHORIZE THE RELEASE OF ANY MEDICAL OR OTHER INFORMATION NECESSARY TO
PROCESS CLAIMS BY MY INSURANCE COMPANY.


__________________________________________________________             ________ / _____/ _______
PATIENT SIGNATURE                                                       DATE


__________________________________________________________             ________ / _____/ _______
INSURED (IF OTHER THAN PATIENT)                                         DATE




                                                                                          Page 4 of 13
                   Southwest Nephrology Associates, L.L.P
                           Internal Medicine, Nephrology and Dialysis
                               7777 Southwest Freeway, Suite 304
                                     Houston, Texas 77074


                       ACKNOWLEDGEMENT OF RECEIPT OF
                         NOTICE OF PRIVACY PRACTICES

                     (You may refuse to sign this acknowledgement.)


By my signature below, I acknowledge that I have received a copy of this office’s Notice
of Privacy Practices (next page).

                   ______________________________________________
                         Patient Name Printed

                   ___________________________________________________________
                          Patient Signature

                   _______________________
                          Date


                                       For Office Use Only


We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices,
but acknowledgement could not be obtained because:

            __     Individual refused to sign

            __     Communications barriers prohibited obtaining the acknowledgement

            __     An emergency situation prevented us from obtaining acknowledgement

            __     Other (please specify):

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________




                                                                                      Page 5 of 13
                            Southwest Nephrology Associates, L.L.P
                                       Internal Medicine, Nephrology and Dialysis
                                           7777 Southwest Freeway, Suite 304
                                                 Houston, Texas 77074

                                  NOTICE OF PRIVACY PRACTICES
 THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
                  AND HOW YOU CAN GET ACCESS TO THEIS INFORMATION.

                                     PLEASE REVIEW IT CAREFULLY.
                     THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give
you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow
the privacy practices that are described in this Notice while it is in effect. This Notice takes effect April 1, 2003, and will remain in
effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted
by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for
all health information that we maintain, including health information we created or received before we made the changes. Before
we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this
Notice, please contact us using the information listed at the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare
operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare
professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification,
licensing, or credentialing activities.

Your Authorization: in addition to our use of your health information for treatment, payment, or healthcare operations, you may
give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an
authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your
authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information
for any reason except those described in this Notice.

To your family and friends: We must disclose your health information to you, as described in the Patient Rights section of this
Notice. We may disclose your health information to a family member, friend, or other person to the extent necessary to help with
your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons involved in care: We may use or disclose health information to notify, or assist in the notification of (including identifying
or locating) a family member, your personal representative or another person responsible for your care, of your location, your
general condition, or death. If you are present, then prior to use or disclosure of your incapacity or emergency circumstances, we
will disclose health information based on a determination using our professional judgment disclosing only health information that is
directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience
with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions,
medical supplies, x-rays, or other similar forms of health information.

Marketing health-related services: We will not use your health information for marketing communications without your written
authorization.


                                                                                                                               Page 6 of 13
Required by law: We may use or disclose your health information when we are required to do so by law.

Abuse or neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a
possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health
information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain
circumstances. We may disclose to authorized federal officials health information required for lawful intelligence,
counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official
having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment reminders: We may use or disclose your health information to provide you with appointment reminders (such as
voicemail messages, postcards, or letters).


PATIENT RIGHTS
Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we
provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You
must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the
contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and
staff time. You may also request access by sending us a letter at the end of this Notice. If you request copies, we will charge you
$0.25 for each page, a reasonable per-hour fee for staff time to locate and copy your health information, and postage if you want the
copies mailed to you. If you request an alternative format, we will charge a cont-based fee for providing your health information in
that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the
information listed at the end of this Notice for a full explanation of our fee structure.)

Disclosure accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health
information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but
not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable,
cost-based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information.
We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative communication: You have the right to request that we communicate with you about your health information by
alternative means or to alternative locations. (You must make your request in writing.) Your request must specify the alternative
means or locations, and provide satisfactory explanation how payments will be handled under the alternative or location you
request.

Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must
explain why the information should be amended.) We may deny your request under certain circumstances.

Electronic notice: If you receive this Notice on our web site or by electronic mail (e-mail), you are entitled to receive this Notice in
written form.

QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your
health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to
have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact listed at
the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will
provide you with the address to file your complaint with the U.S. Department of Health and Human Services, upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint
with us or with the U.S. Department of health and Human Services.

Contact Officer: Cheryl Williamson                     Telephone: (713) 270-4545            Fax: (713) 270-9197

E-mail: swnephrology@gmail.com                         Address: 7777 Southwest Freeway, #304, Houston, TX 77075




                                                                                                                              Page 7 of 13
                                Southwest Nephrology Associates, L.L.P
                                             Internal Medicine, Nephrology and Dialysis
                                                 7777 Southwest Freeway, Suite 304
                                                       Houston, Texas 77074

            CONSENT FOR USE AND DISCLOSURE OF
                  HEALTH INFORMATION
                                                  Include completed Consent in the patient’s chart
SECTION A: PATIENT GIVING CONSENT
Name ______________________________________________________________________________________________
Address _____________________________________________________________________________________________
Telephone (_____) _____-___________ E-mail address _____________________________________________________
Patient number _________________________ Social Security number _________-_______-____________
SECTION B: TO THE PATIENT – PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.
Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to
carry our treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign
this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses
and disclosures we may make of your protected health information, and of other important matters about your protected
health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully before signing
this consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our
privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may
apply to any of your protected health information that we maintain.

You may obtain another copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time, by
contacting Cheryl Williamson, at (713) 270-4545, by fax at (713) 270-9197, or by E-mail at swnephrology@gmail.com.

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation
submitted to the contact person listed above. Please understand that revocation of the Consent will not affect any action we
took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue
treating you if you revoke this Consent.

SIGNATURE

I, (print name) ______________________________, have had full opportunity to read and consider the contents of this
Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my
consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and
healthcare operations.

Patient Signature _________________________________________________________ Date ______/ _____/ ______

If this consent is signed by a personal representative on behalf of the patient, complete the following:

Personal Representative’s Name ___________________________________ Relationship to Patient ______________________
                   YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT


REVOCATION OF CONSENT

I revoke my Consent for your use and disclosure of my protected health information for treatment, payment activities, and healthcare operations
I understand that revocation of my Consent will not affect any action you took in reliance on my Consent before your received this written Notice of
Revocation. I also understand that you may decline to treat or to continue to treat me after I have revoked my Consent.

Patient Signature ____________________________________________________ Date _________/______/ _________

                                                                                                                                                Page 8 of 13
                                                                                      Southwest Nephrology Associates, L.L.P
                                                                                   Internal Medicine, Nephrology and Dialysis
                                                                                            7777 Southwest Freeway, Suite 304
                                                                                                        Houston, Texas 77074

                                             Medical History Questionnaire

Patient ____________________________

Instructions:
        Please complete the form below
        This form will be used to screen any conditions that you may have
   
CONDITIONS: Circle YES or NO as applicable
                                                                                            Ongoing? Is      Stop date -
   Condition           If yes, please       Description/Comment              Start date    condition still   If condition no
                      describe in next                                                     present? Circle   longer exists,
                          column.                                                          YES or NO         give stop-date.
                                                                                           below.
                         Yes     No                                            /   /       Yes      No           /      /
Head problems                                                                  /   /       Yes      No           /      /
                                                                               /   /       Yes      No           /      /
                         Yes     No                                            /   /       Yes      No           /      /
Ear problems                                                                   /   /       Yes      No           /      /
                                                                               /   /       Yes      No           /      /
                         Yes     No                                            /   /       Yes      No           /      /
Nose problems                                                                  /   /       Yes      No           /      /
                                                                               /   /       Yes      No           /      /
                         Yes     No                                            /   /       Yes      No           /      /
Eye problems                                                                   /   /       Yes      No           /      /
                                                                               /   /       Yes      No           /      /
                         Yes     No                                            /   /       Yes      No           /      /
Throat/mouth                                                                   /   /       Yes      No           /      /
problems                                                                       /   /       Yes      No           /      /
                         Yes     No                                            /   /       Yes      No           /      /
Heart problems                                                                 /   /       Yes      No           /      /
                                                                               /   /       Yes      No           /      /
                         Yes     No                                            /   /       Yes      No           /      /
High blood                                                                     /   /       Yes      No           /      /
pressure                                                                       /   /       Yes      No           /      /
                         Yes     No                                            /   /       Yes      No           /      /
High cholesterol                                                               /   /       Yes      No           /      /
                                                                               /   /       Yes      No           /      /
Lungs and                Yes     No                                            /   /       Yes      No           /      /
breathing                                                                      /   /       Yes      No           /      /
problems                                                                       /   /       Yes      No           /      /
                         Yes     No                                            /   /       Yes      No           /      /
Diabetes                                                                       /   /       Yes      No           /      /
                                                                               /   /       Yes      No           /      /
                         Yes     No                                            /   /       Yes      No           /      /
Liver/Gall                                                                     /   /       Yes      No           /      /
bladder problems                                                               /   /       Yes      No           /      /




                                                                                                                     Page 9 of 13
                                                                          Southwest Nephrology Associates, L.L.P
                                                                       Internal Medicine, Nephrology and Dialysis
                                                                                7777 Southwest Freeway, Suite 304
                                                                                            Houston, Texas 77074

                                          Medical History Questionnaire

Patient ____________________________

CONDITIONS: Circle YES or NO as applicable
                                                                                Ongoing? Is      Stop date -
    Condition           If yes, please    Description/Comment    Start date    condition still   If condition no
                       describe in next                                        present? Circle   longer exists,
                           column.                                             YES or NO         give stop-date.
                                                                               below.
                         Yes     No                                /      /    Yes      No           /       /
Stomach                                                            /      /    Yes      No           /       /
problems                                                           /      /    Yes      No           /       /
                         Yes     No                                /      /    Yes      No           /       /
Kidney/Bladder                                                     /      /    Yes      No           /       /
Problems                                                           /      /    Yes      No           /       /
                         Yes     No                                /      /    Yes      No           /       /
Prostate                                                           /      /    Yes      No           /       /
problems                                                           /      /    Yes      No           /       /
                         Yes     No                                /      /    Yes      No           /       /
Breast problems                                                    /      /    Yes      No           /       /
                                                                   /      /    Yes      No           /       /
Uterine/ovarian/         Yes     No                                /      /    Yes      No           /       /
cervical                                                           /      /    Yes      No           /       /
problems                                                           /      /    Yes      No           /       /
Epilepsy, seizures,      Yes     No                                /      /    Yes      No           /       /
stroke, Neurological
                                                                   /      /    Yes      No           /       /
problems
                                                                   /      /    Yes      No           /       /
                         Yes     No                                /      /    Yes      No           /       /
Arthritis/                                                         /      /    Yes      No           /       /
rheumatism                                                         /      /    Yes      No           /       /
                         Yes     No                                /      /    Yes      No           /       /
Musculoskeletal                                                    /      /    Yes      No           /       /
problems                                                           /      /    Yes      No           /       /
                         Yes     No                                /      /    Yes      No           /       /
Skin/nail                                                          /      /    Yes      No           /       /
problems                                                           /      /    Yes      No           /       /
                         Yes     No                                /      /    Yes      No           /       /
Psychological                                                      /      /    Yes      No           /       /
problems                                                           /      /    Yes      No           /       /
                         Yes     No                                /      /    Yes      No           /       /
Anemia / Blood                                                     /      /    Yes      No           /       /
disease                                                            /      /    Yes      No           /       /
                         Yes     No                                /      /    Yes      No           /       /
Others                                                             /      /    Yes      No           /       /
                                                                   /      /    Yes      No           /       /




                                                                                                         Page 10 of 13
                                                                                 Southwest Nephrology Associates, L.L.P
                                                                              Internal Medicine, Nephrology and Dialysis
                                                                                       7777 Southwest Freeway, Suite 304
                                                                                                   Houston, Texas 77074

                                         Medical History Questionnaire

Patient ____________________________

SURGERIES / HOSPITALIZATIONS: List all including childbirth, or ___ None
   Date                                         Surgery and Hospitalizations
    /   /
    /   /
    /   /
    /   /
    /   /
    /   /
    /   /


ALLERGIES:     List all, including environment, food, dyes, & medications or ___ None
     Date                            Allergy                              Reaction / outcomes / medications taken
   /    /
   /    /
   /    /
   /    /
   /    /


MEDICATIONS: What over-the-counter, herbal remedies or prescription medication do you take? Or __ None
 Medication  Dose     #                  Reason                     Start       Ongoing? Are you Stop date (If not,
                   times/                                            Date          still taking this when did you
                                                                                    medication?)        stop?)
                     day
                                                                          /   /      __ Yes    __ No          /      /
                                                                          /   /      __ Yes    __ No          /      /

                                                                          /   /      __ Yes    __ No          /      /

                                                                          /   /      __ Yes    __ No          /      /

                                                                          /   /      __ Yes    __ No          /      /

                                                                          /   /      __ Yes    __ No          /      /

                                                                          /   /      __ Yes    __ No          /      /

                                                                          /   /      __ Yes    __ No          /      /

                                                                          /   /      __ Yes    __ No          /      /

                                                                          /   /      __ Yes    __ No          /      /

                                                                          /   /      __ Yes    __ No          /      /




                                                                                                                  Page 11 of 13
                                                                                  Southwest Nephrology Associates, L.L.P
                                                                               Internal Medicine, Nephrology and Dialysis
                                                                                        7777 Southwest Freeway, Suite 304
                                                                                                    Houston, Texas 77074

                                               Medical History Questionnaire

Patient ____________________________


SOCIAL HISTORY
                Tobacco                                         Alcohol                          Caffeine
__ Never Used                                __ Never Used                        __ Never Used
__ Ex-user                                   __ Ex-user                           __ Ex-user
__ Currently use                             __ Currently use                     __ Currently use

Start date _____/ ____/_______               Start date _____/ ____/_______       Start date _____/ ____/_______
Stop date _____/ ____/_______                Stop date _____/ ____/_______        Stop date _____/ ____/_______

# cigarette Packs / day _______
                                             Beer: # cans / week ______
# cigars / day _______
                                             Wine: # glasses / week ______        # ounces / day _______
# pipefuls / day _______
                                             Liquor: # drinks / week _______
# patches / day ________

Drug use
__ Never used            __ Ex-user

    1.   Have you used illicit or recreational drugs in the past 12 months?
         __ No     __ Yes If yes, date last used: ____/ ____/ ______
    2.   Have you ever been in drug / alcohol rehab?
             __ No      __ Yes If yes, date: ____/ ____/ ______




                                                                                                               Page 12 of 13
                                                                                      Southwest Nephrology Associates, L.L.P
                                                                                   Internal Medicine, Nephrology and Dialysis
                                                                                            7777 Southwest Freeway, Suite 304
                                                                                                        Houston, Texas 77074

                                            Medical History Questionnaire

Patient ____________________________

FOR WOMEN ONLY;

Please complete either Section A or Section B. Date of last menstrual period ____/ _____/ ______

Section A
Able to have children (childbearing potential)    Check primary birth control method used
      Oral contraceptive pill                      Condoms and foam / gel                   Vaginal condom
      Contraceptive injection                      Diaphragm and foam / gel                 IUD
      Contraceptive implant (Norplant)             Condoms only                             None
      Partner had vasectomy                        Abstinence                               Other, type:
      Rhythm                                       Withdrawal


Section B
Non-childbearing by means of (check one, and specify date)
      Hysterectomy                           Date ___/ ___/ _____
      Tubal ligation (tubes tied)            Date ___/ ___/ _____
      Bilateral oophorectomy                 Date ___/ ___/ _____
      Natural post-menopause                 Date of last natural menstrual period ___/ ___/ ______


Participant Signature ______________________________________           Date _____/ ______/ _________

Staff Signature ____________________________________________           Date _____/ ______/ _________

* NOTE: All updates must be initialed and dated

UPDATE(S) OR Additional Information                                                         Initials / Date




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