Please print all information in the spaces provided. Be sure to complete and sign the statement on the bottom of this form. Last Name First Name M.I.

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Hannah McGee
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1 fax gastroconsultantsmedgrp.com Patient Information Form Thomas J. Imperato, M.D. John T. Hata, M.D. Rekha Cheruvattath, M.D. Please print all information in the spaces provided. Be sure to complete and sign the statement on the bottom of this form. Last Name First Name M.I. Home Address Home Phone Work Phone Employer Name and Address Social Security Number Date of Birth Name and Phone Number of person to contact in the case of an emergency Primary Insurance Company Name and Phone Number Billing Address Name of Insured and Relation to Patient Insured s ID Number Group Number Secondary Insurance Company Name and Phone Number Billing Address Name of Insured and Relation to Patient Insured s ID Number Group Number I hereby authorize payment of medical benefits billed to my insurance to Gastroenterology Consultants I hereby accept responsibility for payment for any service(s) provided to me that is not covered by my insurance. I also accept responsibility for fees that exceed the payment made by my insurance, if the Practice does not participate with my insurance. I agree to pay all copayments, coinsurance, and deductibles at the time the service is rendered. I also agree to inform the office of any changes in insurance coverage prior to my visit. signature of patient or guardian date -1- POS Reorder #

2 fax gastroconsultantsmedgrp.com CONSENT FOR RELEASE OF INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS I,, hereby authorize Gastroenterology Consultants to use and/or disclose my health information which specifically identifies me or which can reasonably be used to identify me to carry out my treatment, payment and health care operations. I understand that while this consent is voluntary, if I refuse to sign this consent, Gastroenterology Consultants can refuse to treat me. I have been informed that Gastroenterology Consultants has prepared a notice ("Notice") which more fully describes the uses and disclosures that can be made of my individually identifiable health information for treatment, payment and health care operations. I understand that I have the right to review such Notice prior to signing the consent. I understand that I may revoke this consent at any time by notifying GCMG, Inc., in writing, but if I revoke my consent, such revocation will not affect any actions that GCMG, Inc. took before receiving my revocation. I understand that GCMG, Inc. has reserved the right to change his/her privacy practices and that I can obtain such changed notice upon request. I understand that I have the right to request that GCMG, Inc. restricts how my individually identifiable health information is used and/or disclosed to carry out treatment, payment or health operations. I understand that GCMG, Inc. does not have to agree to such restrictions, but that once such restrictions are agreed to, GCMG, Inc. must adhere to such restrictions. Do we have permission to: Yes No Leave a message on your answering machine at home Leave a message at your place of employment Discuss your medical condition with any member of your household? If yes whom: Relationship Signature of patient or patient's representative (Form MUST be completed before signing.) Date Printed name of patient or patient's representative Relationship to the patient -2- POS Reorder #

3 History (PATIENTS : PLEASE COMPLETE FORMS) Name Date of Birth Age Referring Physician Date of Visit Chief Complaint (Main Reason for Visit) _ Abdominal pain _ Heartburn/Indigestion _ Abnormal X-Ray or Imaging exam _ Hepatitis C _ Hepatitis B _ Abnormal liver enzymes _ Nausea or vomiting _ Anemia _ Swallowing difficulty _ Blood in stool _ Weight loss/poor appetite _ Colon screening _ Other not listed Constipation Diarrhea Change in Bowel Habits History of Present Illness Patient Notes (Please describe the nature of your problem in the space below. Include things like how long you've noticed the problem, is it steady or does it come and go, does it occur day or night, or before or after meals. Where is the symptom located, where does it go and what does it feel like? Is it sharp, burning, cramping, dull, full etc? What makes it better and what makes it worse? Rate severity (1 mildest - 10 most severe) and whether it is improving or worsening over time. What other symptoms do you associate with your main problem?) Previous testing or treatments for this problem -3- POS Reorder #

4 Personal Medical History Surgery: Details Date / Hospital _ Appendectomy Breast Gallbladder Hernia repair Hysterectomy / ovaries Other intestinal/abdominal Tonsillectomy Stomach/duodenal ulcer Surgery not listed above Hospitalizations other than Surgery Date / Hospital Current Medical Problems _ Arthritis Asthma Atrial fibrillation/ other rhythm disturbance Anxiety/Depression Chronic bronchitis/emphysema Congestive Heart Failure Coronary artery disease/angina Diabetes mellitus High blood pressure High cholesterol/triglycerides Kidney failure Osteoporosis/osteopenia Sleep apnea Thyroid problems Other Medications: (Include over the counter and herbal products) Name Dose / Frequency Condition Being Treated / Duration Allergies to Medications: (Include latex/tape, iodine and serious adverse reactions other than allergy) Medication Reaction -4- POS Reorder #

5 Social History Tobacco _ No _ Yes _ Quit / when Packs per day # Years Alcohol _ No _ Yes _ Quit / when Drinks per wk # Years Recreational Drug Use _ No _ Yes _ Quit / when Used needles Drugs used Diet _ vegetarian _ lactose-free _ caffeine-free _ diabetic _ regular _ other Marital Status _ Married _ Single _ Divorced _ Widow/Widower _ Occupation Family History: (include age of diagnosis in affected family member) Father Mother Brother/Sister Other/ Other Generations Colon cancer Colon polyp Uterine/ovarian cancer Stomach/small bowel cancer Renal/ urethral cancer Breast cancer Liver disease/ Hemochromatosis Gallbladder disease Colitis/Crohn's disease Other Review of Systems (check if you have any of the following and describe further in space below) Gastrointestinal General _ Y _ N Heartburn/regurgitation _ Y _ N Intolerance to milk _ Y _ N Decreased appetite _ Y _ N Difficulty swallowing _ Y _ N Intolerance to other foods _ Y _ N Unexpected weight loss _ Y _ N Painful swallowing _ Y _ N Jaundice _ Y _ N Unexpected weight gain _ Y _ N Filling up quickly at meals _ Y _ N Gallstones _ Y _ N Fatigue _ Y _ N Nausea or vomiting _ Y _ N Hepatitis A, B, C, other _ Y _ N Fever or Chills _ Y _ N Abdominal pain _ Y _ N Cirrhosis _ Y _ N Irregular bowel habits _ Y _ N Fluid in abdomen (ascites) Eyes _ Y _ N Bloating/gas _ Y _ N Pancreatitis _ Y _ N Blind field of vision _ Y _ N Incomplete evacuation of bowels _ Y _ N Cataracts _ Y _ N Symptoms improve with evacuation Skin _ Y _ N Blood in stool or on toilet paper _ Y _ N Rash ENT _ Y _ N Mucous in stool _ Y _ N Itching _ Y _ N Hearing loss/ ringing _ Y _ N Loss of control of bowels _ Y _ N Unusual hair loss _ Y _ N Sore throat/hoarseness _ Y _ N Sinusitis/Sinus drainage Respiratory/Lung Cardiovascular Renal/Urinary/Kidney _ Y _ N Sleep apnea / CPAP mask _ Y _ N Chest pain, pressure, angina _ Y _ N Renal failure/insufficiency _ Y _ N Respiratory complications with sedation _ Y _ N Coronary artery disease _ Y _ N Electrolyte disturbances _ Y _ N Chronic bronchitis/emphysema _ Y _ N High blood pressure _ Y _ N Kidney stones _ Y _ N Difficulty breathing _ Y _ N Swelling in feet or legs _ Y _ N Difficulty with urination _ Y _ N Persistent cough _ Y _ N Abnormal heart rhythm _ Y _ N Urinary tract infections _ Y _ N Asthma _ Y _ N Prostate cancer/enlarged Endocrine Gynecology Musculoskeletal _ Y _ N Diabetes _ Y _ N Pregnant now? _ Y _ N Joint pain/arthritis _ Y _ N Thyroid disease _ Y _ N Endometriosis _ Y _ N Back / neck pain _ Y _ N Osteoporosis/osteopenia _ Y _ N Heavy periods _ Y _ N Muscle aching/weakness Neurologic Psychiatric Blood / Lymph _ Y _ N Headaches _ Y _ N Depression _ Y _ N Anemia _ Y _ N Strokes/ CVA _ Y _ N Anxiety _ Y _ N Bruise easily _ Y _ N Seizures _ Y _ N Suicide attempt _ Y _ N Past blood transfusion _ Y _ N Swollen/tender lymph node Comments -5- POS Reorder #

HEALTH HISTORY QUESTIONNAIRE

L 3/11 Page 1 HEALTH HISTORY QUESTIONNAIRE NAME: DATE: HOME ADDRESS: HOME PHONE: WORK PHONE: CELL PHONE: OTHER PHONE: EMPLOYER: OCCUPATION: EXPLAIN YOUR JOB DUTIES: DATE OF BIRTH: SEX: MALE /FEMALE SS#