1

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*Name: Last ___________________________________ *First ________________________________ Middle _________________

*2ddress _____________________________________________________________________________________________________

*3it4 ____________________________________________ *5tate _________________ * 6i7______________________________

*89:;e: <:me _____________________________ *3ell_________________________ *=:r> _____________________?@t______

*?Amail address _________________________________________ *3a; Be se;d remi;ders C4 eAmail :r te@tD 4es E ;:

:1;%%%%�,-01%%%%�/1,-01%%%%%%*FGHGIG________________________________ *5H3 5?3J ____________A__________A__________

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*LaMe:_______________________________________ *La;NOaNe s7:>e; at 9:me__________________________________

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*

!"#$%&#'()!%*(+&",)-$(#+*.All information contained here will not be released except when you have authorized us to do so. Please answer all questions to the best of your knowledge. Theinformation provided by you will be used by your physician in decisions regarding your care.

?hat is your primary reason for seeing the doctor@ AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

?ho referred you to us@ AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA?ho is your primary care physician@ AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

?hat other health complaints do you have@AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

Bist operations and serious illness. Bist any Cospitalizations that you have had.

AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAADearAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAADearAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAADearAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAADearAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAADearAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAADearAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAADearAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAADearAAAAAAA

Cave /01 ever had any of the following@ EFf any box is markedG please specify age at onset.H

� -2345)"55367 age AAAAAA �8/93::)(14;24/ �(52<5 �-2345)=14>14 �(54072 �-?; )8!00")!42::142)

�-?; )# 0!2:5240! � #0<;2:5?$2)-2345)%3?!142 �&3!$2)'?:04"24))�&3!$2)429!362>2<5))�"54?3!)%?(4?!!35?0<

�'?3(252:)))�,1<;)'?:23:2) �#+!') � !362>3724)(43<"))))))))))))))) �'2*?(4?!!350r (43<"AAAAAAAAAAAAAAA

Cas anyone in your immediate family ever had@

-2345)"55367 AA Iother AAJather AA Iaternal Krandmother AA Iaternal Krandfather AAPaternal Krandmother AA Paternal Krandfather AALibling

-2345)>14>14 AA Iother AAJather AA Iaternal Krandmother AA Iaternal Krandfather AAPaternal Krandmother AA Paternal Krandfather AALibling

-?; )(!00")))AA Iother AAJather AA Iaternal Krandmother AA Iaternal Krandfather AAPaternal Krandmother AA Paternal Krandfather AALibling

#0<;2:5?$2) 2345)*3?!142)AA Iother AAJather AA Iaternal Krandmother AA Iaternal Krandfather AAPaternal Krandmother AA Paternal Krandfather AALibling))

#0<;2<?53!) 2345)'?:23:2)AA Iother AAJather AA Iaternal Krandmother AA Iaternal Krandfather AAPaternal Krandmother AA Paternal Krandfather AALibling

'?3(252:)AA Iother AAJather AA Iaternal Krandmother AA Iaternal Krandfather AAPaternal Krandmother AA Paternal Krandfather AALibling)

(54072)AA Iother AAJather AA Iaternal Krandmother AA Iaternal Krandfather AAPaternal Krandmother AA Paternal Krandfather AALibling

,1<;)"?:23:2)AA Iother AAJather AA Iaternal Krandmother AA Iaternal Krandfather AAPaternal Krandmother AA Paternal Krandfather AALibling

+

!"# %& '!)*+),'! "" #other "")ather "" #aternal -randmother "" #aternal -randfather ""Paternal -randmother "" Paternal -randfather ""2ibling

-./012/34%51&01+%8%%4:4/1;4

Are you now or have you in the last < months experienced lightheadedness or dizzinessA :)*%%,%%%2'Bhest pain with exertionA """"""""" b.D at restA """"""""""2hortness of breath with exertionA """"""""" b.D at restA """"""""""

Eake from sleep because of shortness of breathA :)*%%,%%%2'Pain or swelling in legsA :)*%%,%%%2'2leeplessness or tiredness :)*%%,%%%2'2leep with head elevated to facilitate breathingA :)*%%,%%%2'Go you have headachesA :)*%%,%%%2'Hinging in earsA :)*%%,%%%2'IAGJK2L Ehen was your last menstrual periodA """"""""""""""""""" Mreast Jmplants :)*%%,%%%2'

;1'0#./082%-58%0?1Iist all medications you are presently takingL;)""&A+"'B%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%''*A#)%%%%%%%%%%%%%%%%,)-D)B&E% % ;)""&A+"'B%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%''*A#)%%%%%%%%%%%%%%%%,)-D)B&E))))))))))))))))))))))))))))%%%%%%))))))))G#%%%%))))))))))))))%% % ))))))))))))))))))))))))))))%%%%%%))))))))G#%%%%))))))))))))))))))))))))))))))))))))))))))%%%%%%))))))))G#%%%%))))))))))))))%% % ))))))))))))))))))))))))))))%%%%%%))))))))G#%%%%))))))))))))))))))))))))))))))))))))))))))%%%%%%))))))))G#%%%%))))))))))))))%% % ))))))))))))))))))))))))))))%%%%%%))))))))G#%%%%))))))))))))))))))))))))))))))))))))))))))%%%%%%))))))))G#%%%%))))))))))))))%% % ))))))))))))))))))))))))))))%%%%%%))))))))G#%%%%))))))))))))))))))))))))))))))))))))))))))%%%%%%))))))))G#%%%%))))))))))))))%% % ))))))))))))))))))))))))))))%%%%%%))))))))G#%%%%))))))))))))))))))))))))))))))))))))))))))%%%%%%))))))))G#%%%%))))))))))))))%% % ))))))))))))))))))))))))))))%%%%%%))))))))G#%%%%))))))))))))))))))))))))))))))))))))))))))%%%%%%))))))))G#%%%%))))))))))))))%% % ))))))))))))))))))))))))))))%%%%%%))))))))G#%%%%))))))))))))))

Go you have any drug or food allergiesA :)*%,%%2' Jf yesN list allergies and reaction. Are you allergic to JodineA :)*%,%%2'

#edication Heaction #edication Heaction""""""""""""""""""""" """""""""""""""" """"""""""""""""""""" """"""""""""""""

""""""""""""""""""""" """""""""""""""" """"""""""""""""""""" """"""""""""""""

-./012/34%48#0.?%!04/85:

Oave you ever smokedA :)*%,%2' Pear quit or age when quit """""""""""" Go you currently smokeA """"""""""""" Packs per day """""""""" Goyou useL """""Bhewing Tobacco """""Bigar """""Pipe """"""Sther

Please specify the number of cups per day you drink of each of the following caffeinated drinksL""""" Boffee """"" Tea """""2oda """"" Knergy Grink

Go you regularly drinkL Jf yesLMeer """"""""" Tumber of drinks per day """""""""""Tumber of drinks per month"""""""""+ine """""""" Tumber of drinks per day """""""""""Tumber of drinks per month"""""""""Iiquor """"""" Tumber of drinks per day """"""""""" Tumber of drinks per month""""""""" Oave you ever had a drug problem or are you using recreational drugs nowA :)*%,%2' SccupationL """"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" Js there much tension or pressure in your UobA :)*%,%2'

,

"umber of children0 111111 Permission to leave message on answering machine !"#$,$&'

"ame0 11111111111111111111111111111111111111 9ate0 1111111111111111Please check all symptoms that you are having.

#)*",'$)#./!)*11111>urmur11111?rregular @eart Ahythm11111Palpitations11111Bqueezing of the chest11111Ehest Pain11111Ehest tightness or discomfort11111Bhortness of breath 11111Bhortness of breath with exertion

1)*#.$&'#"11111@earing loss11111Ainging in ears11111Abnormal mucous membranes13"#11111Hlurred or 9ouble vision11111Eontacts or Ilasses4#3. ,)6*,.11111Anxiety problems111119epressive symptoms11111Personality or >ood changes786"9/:"86)*311111Jdema K Bwelling 11111Bweating11111Hruising11111Bkin lesions11111Bkin cancer11111Aash or itching on skin/)#6*',86"#6,8)!11111Abdominal pain11111Leight gain11111Leight loss11111Ehange in appetite11111"ausea or Momiting111119iarrhea or Eonstipation11111?ndigestion or @eartburn11111Aeflux</#./!'#="!"6)!11111Arthritis11111Hack or "eck pain11111Neg pain11111Arm pain11111Iout&"/*'!'9,.)!11111Iait disturbance trouble walking11111Beizures11111Eonfusion or >emory loss11111Leakness or Oatigue11111"umbness or Tingling11111@eadaches111119izziness11111Byncope QPassed outR11111Bwallowing difficulties

-

!!!!!"ifficulties in -peech!"#$%&'()&*!!!!!0ongestion or 4heezing!!!!!0ough/",%()-&%,'&*!!!!!6ncontinence!!!!!7requent urination!!!!!pain or burning with urination!!!!!<lood in >rine

.-( )&%0'(%),1*)&1!"!"'#"1)*14""%6'!1!"6)&"#1?from1',)( "&1*'6%!%(*1()1.'&.#.!':;11

Patient BameC !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

<irth "ateC !!!!!!!!!!!!!!!! -ocial -ecurity BumberC !!!!!!!!!!!!!!!

<elow please list names of any "octors you have seen or any Fospitals you have been in recently. 4e willrequest records for your chart.

2>!"'#"1!%#(1'!!1')6()&#1',"1?)#$%('!#13"1,"""1()1A"(1&"6)&"#1*&)B1

6 hereby authorizeC !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

To release all of the information contained in my medical records toC

.'&.#.!':;'&415)0 '*'1#41E)F ),.1'&416"',1;41IF3",%(".1'&41+'!("&1>)!!)

> ),"7189:;<==;<===%'>7189:;<==;<==<

IThe information being released will only be used for medical purposes. IThis authorization is valid for one year from the date of signing.IThe patient or hisJher representative may revoke this consent at any time.

.

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

"ignature of Patient or /epresentative 3ate

P/45676T649 4: /;36"<=4">/;? This information is being disclosed from medical records whose confidentiality is protected by law. Any further disclosure of this

information must be by written consent of the person to whom it pertains. A general authorization for release of medical other information if held by another party

is not sufficient for this purpose. The party to whom this consent is addressed releases this information by reason of the signature noted above and is not

responsible for redisclosure for any purpose.

!"# %&'0)#'%*+*%&+-.!.)0.+%*+1."'3)!+-.3%&"0+4%7

7y signing this formK 6 L!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! authorize Advacardio to release confidential health information about meK by releasing a

copy of my medical recordsK or a summary or narrative of my protected health informationK to the 6.&0%*201+%&+.*#'#9 listed below.

:)#'.*#+;)<.7+ + +

='<'#)#'%*0+%*+# .+'**%&<)#'%*+9%"+<)9+&.!.)0.+0"(?.3#+#%+# '0+-.!.)0.+%%&<+)&.+)0+*%!!%307+

@-.!.)0.+<9+6&%#.3#."+ .)!# +'**%&<)#'%*+#%+# .+*%!!%3'*C+6.&0%*201,.*#'#97+;)<.7++

E#&..#7++

#'#97+++ + + + + E#)#.7+ + + + A'67

4 .+&.)0%*0+%&+6"&6%0.0+*%&+# '0+&.!.)0.+%*+'**%&<)#'%*+)&.+)0+*%!!%307

:)#'.*#+E'C*)#"&.+B%&+6)&.*#.+C")&"')*+%&+!.C)!+&.6&.0.*#)#'$.C7

L!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 3ate7 !!!!!!!!!!!!!!!!!!!!!!

!"! % &"'(:""&"$%&'(&)")%")*("+(,(-'("%."-&/"0%'1)1/("%+"&(3-)1/(")(')"+('4,)".%+"0&67"%+"2&3"1&.($)1%&4"-&)15%<1(')%"0&67"%+"1&.($)1%&"=1)*"-&/"%)*(+"$-4'-)1/("-3(&)"%."0&67"=1)*")*("+(')"%.">/">(<1$-,"+($%+<'?"""""*itial: 'ate:

6

! understand that you will provide this information within 56 days from receipt of request and that a fee for preparing and

furnishing this information may be charged according to rulings set forth by the Texas =tate >oard of ?edical @xaminers.

Authorization Dorm for Eelease of Protected Gealth !nformation

.

!"#$%&#'(")%7' ' ' ' ' ' ' ' ' '

Hontact !nformationI ?ay we leave messages in your voice mailI � Jes or � Ko.

+%!-3'/!%"0%'!$0#'"&1'*")$!1')%)(%4'-4'! 10$6$"&0'3%')"1'0 "4%'1-74')%"$6"!'$&*-4)"#$-&'3$# 4Eelease my protected health information to the following personLsMNentityI

KameI OOOOOOOOOOOOOOOO OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO EelationshipI OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOPhoneIOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO

KameI OOOOOOOOOOOOOOOO OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO EelationshipI OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOPhoneIOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO

KameI OOOOOOOOOOOOOOOO OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO EelationshipI OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOPhoneIOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO

KameI OOOOOOOOOOOOOOOO OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO EelationshipI OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOPhoneIOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO

This authorization shall be in force and effective until the following event andNor dateI OOOOOOOOOOOOOOOOOOOOOOOOO

The reasons or purposes for this release of information are as followsI

:'7&"%40#"&"'# "#':' "$%'# %'4$< #'#-'4%$-=%'# $0'"7# -4$0"#$-&.'$&'34$#$&<.'"#'"&1'#$)%'(1'0%&"$&<'"'34$##%&'&-#$*$6"#$-&'#-'# %'*-!!-3$&<'/%40-&'"#'# %'/4"6#$6%7''

@"$"6"4"$-'2!4$$"61'B**$6%41.8<=8D':'(-4# 'H %'+--"!"&"0.'HE'FF=9G''':'7&"%40#"&"'# "#'"'4%$-6"#$-&'$0'&-#'%**%6#$$%'#-'# %'%>#%&#'# "#'# %'/4"6#$6%' "0'4%!$%"'-&'# $0'"7# -4$0"#$-&'$&'$#0'"6#$-&04''@!0-.'"'4%$-6"#$-&'$0'&-#'%**%6#$$%'$*'# $0"7# -4$0"#$-&'3"0'-(#"$&%"'"0'"'6-&"$#$-&'-*'-(#"$&$&<'$&074"&6%'6-$%4"<%.'"0'-# %4'!"3'/4-$$"%0'# %'$&074%4'3$# '# %'4$< #'#-'6-&#%0#'"'6!"$)'7&"%4'# %'/-!$61'-4'# %/-!$61'$#0%!*4'

! understand that information used or disclosed pursuant to this authorization may be subPect to redisclosure by the recipient and may no longer be protected by federal

G!PAA privacy regulations.

H %'/4"6#$6%'3$!!'&-#'6-&"$#$-&')1'#4%"#)%&#.'/"1)%&#.'"&"'%&4-!!)%&#'$&'"' %"!# '/!"&'-4'%!$<$($!$#1'*-4'(%&%*$#0'-&'3 %# %4':'/4-$$"%'"7# -4$0"#$-&'*-4'# %'4%-7%0#%"70%'-4'"$06!-074%4

=ignature of Patient or Personal EepresentativeOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOQateIOOOOOOOOOOOOOOOOOOOOOOOOOOOO

Kame of Patient or Personal EepresentativeI OOOOOOOOOOOOOOOOOOOOOOOOQescription of Personal Eepresentative!s Authority

7

!y signing this form. / authorize you to use and disclose the protected health information described below

!"#$%3!("*(+($,-%*-/($1(3-%*-2%,1"(-%*-341$5"6-345",1"(7

/ have reviewed this office!s <otice of Privacy Practices. which explains how my medical information will be used and disclosed. / understand that / am entitled to receive a copy of this document.

)))))))))))))))))))))))))))))))))))))))))- --------- )))))))))))))))))))))))))))))))))))))))))91*$5,:4(-%*-35,1($,-%4-3(47%$5!-/(;4(7($,5,1$(-- - - - - - '5,(

@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@<ame of Patient or Personal Aepresentative Bescription of Personal Aepresentative!s Authority

Dor office staff use onlyE/f the patient refuses to a written acknowledgement of the <otice of Privacy Practice. please indicate your commentsE

<ameE @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ BateE @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@

=>'?#!/>-!2'-#A==>/#?!B-?29H/!2#>-9?/2!EH/>-A2-%?B>-

/ hereby request that payment of authorized Hommercial /nsurance andIor Jedicare benefits be made on my behalf to AdvacardioandIor Br. Kokhon for any services furnished me by the company listed. / authorize any holder of Jedical information about me torelease to Jedicare andIor Hommercial /nsurance and its agents any information needed to determine these benefits or thebenefits payable to related services.

/ understand my signature below request that payment be made and authorized release of medical information necessary to paythe claim. /f "other health insurance# is indicated in !lock $ of the OHDAPQR%% form or elsewhere on other approved claim formsor electronically submitted claims. my signature authorizes releasing of the information to the insurer or agency shown. /nJedicare assigned cases. the provider or supplier agrees to accept the charge determined of the Jedicare Harrier as the fullcharge. and the patient is responsible for only the deductible. coPinsurance. and nonPcovered services. HoPinsurance and thedeductible are based upon the charge determination of the Hommercial /nsurance andIor Jedicare Harrier.

8

Patient!s Printed ,ame.////////////////////////////////////////////////////////////////////////////////

Patient!s 0ignature.////////////////////////////////////////////////////////////// 3ate./////////////////