Laila Hirjee, M.D. P A 5617 Belmont Ave Suite 103-D Dallas, Tx 75206 Ph: 214-824-3333 Fax: 214-824-3131

New Patient Information** PLEASE UNDERSTAND THAT LAILA HIRJEE, M.D. WILL NOT BE ABLE TO SCHEDULE

PATIENT AN APPOINTMENT UNTIL ALL INSURANCE IS VERIFIED AND COPIES OF CARDS ARE OBTAINED**

Today’s Date _____________ Facility Name ___________________________________ Room #______________

Patient’s Last Name ___________________First________________Middle Initial_____ Home Phone_______________

Patient’s Address _______________________________City___________________State________Zip Code__________

Patient’s SSN_________________________ Sex □ Male □ Female Date of Birth______________________

Marital Status M D W S Pharmacy Name / Phone Number_____________________________________

Current Home Health Agency or CBA Organization You Are Using__________________________________________

Please List ALL Allergies to Medicine or Food_______________________________________________________________________________________________________________________________________________

Are You A DNR □ Yes □ No Do You Have A Living Will □ Yes □ No

Would you like more information regarding Advanced Directives? □ Yes □ No

INSURANCE INFORMATIONPLEASE HAVE YOUR INSURANCE CARD SO WE MAY MAKE A COPY FOR OUR

RECORDS

Medicare Number____________________________________ (Medicare must contain Medicare Part B Coverage)

Secondary Insurance Name___________________________ Policy ID#________________ Group #______________

Secondary Insurance Address___________________________________________Phone#_______________________

Name of Policy Holder of Secondary Insurance_________________________Relationship To Patient____________

RESPONSIBLE FINANCIAL PARTY ( PLEASE FILL OUT COMPLETELY)

Name _________________________________ Address_________________________________________________

City_____________________________________ State_______________________ Zip Code__________________

Relationship _______________________________________________ Use as emergency contact? □ Yes or □ No

Home Number____________________ Work Number________________________ Cell Phone________________

Power Of Attorney Name:________________________________________ Phone #___________________________

PREVIOUS PHYSICIAN INFORMATIONCurrent Primary Physician______________________________________________ Phone Number______________Address__________________________________________________________________________________________My Hospital Of Choice Is_________________________________________________________________________________ (initial) I do hereby give my permission and consent for medical treatment by Laila Hirjee, M.D. PA______ (initial) ) I understand that I will be financially responsible for payment of services if Medicare or other insurance denies payment..______ (initial) I agree to be financially responsible for any testing or treatment ordered by the doctor that may not be considered by my insurance company to be medically necessary.

_____________________________________________________________ ________________________Signature Date

Laila Hirjee, M.D. P A 5617 Belmont Ave Suite 103-D Dallas, Tx 75206 Ph: 214-824-3333 Fax: 214-824-3131

Authorization for Release of Medical Health Information(In compliance with HIPPA this does not authorize release of Psychotherapy Information)

I hereby authorize _____________________________________________________________________________________________________________________________

(Entity/Person from Whom Records are Requested)

_______________________________________________________________________________________________________________________________________

to disclose my individual identifiable health information as described below, which may include information concerning communicable diseases such as Human Immunodeficiency Virus (“HIV”) and Acquired Immune Deficiency Syndrome (“AIDS”), mental illness (except for psychotherapy notes), chemical or alcohol dependency, laboratory test results, medical history, treatment, or any other such related information. I understand that this authorization is voluntary and I may refuse to sign this authorization. I further understand that my health care and the payment of my health care will not be affected if I do not sign this form.

I understand that if the recipient authorized to receive the information is not a covered entity, e.g. insurance company or non-health care provider; the released information may no longer be protected by federal and state privacy regulations.

_______________________________________ ________________ _____________________Patient’s Name Patient’s DOB Patient’s SSN

Date(s) of service (if known):___________________________________________________________________________________________________________________

Description of Information To Be Released: (check all that apply)

□ Entire Medical Record □ Prescriptions□ Medical History, Examination, Reports □ Hospital Records Including Reports□ Allergy Records □ Laboratory Reports□ Consultations □ Immunizations

□ Surgical Reports □ X-ray Reports□ Treatment or Tests □ Billing and Payment Information□ Other (be specific):__________________________________________________________________________________________________________

Description of the purpose of the use and/or disclosure:

_________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________

The health information described herein shall be released to: _____Hospital; __X__ Physician; _____Insurance Company; _____ Attorney; _____Patient; _____Other (check the appropriate category)

Please Release The Information To The Following Physician:

Laila Hirjee, M.D. PA 5617 Belmont Ave Suite 103-D Dallas Texas 75206 214-824-3333 214-824-3131__ (Physician Name) (Address) (City) (State) (ZIP) (Phone)

(Fax)

I understand that this authorization will expire by law in 180 days from the date of this authorization unless I otherwise specify. I desire this authorization to be in effect until ___________________________________.

(expiration event/date)

I further understand that I may revoke this authorization at any time by notifying____________________________________ in writing at __________________________________________________. I also understand that the written revocation must be signed and dated with a date that is later than the date on this authorization. The revocation will not affect any actions taken before the receipt of the written revocation.

___________________________________________ __________________________Signature of Patient or Patient’s Representative Date

___________________________________________Printed Name of Patient’s Representative

___________________________________________ ___________________________________________Relationship to Patient Legal Authority (attach supporting documentation)

Laila Hirjee, M.D. P A 5617 Belmont Ave Suite 103-D Dallas, Tx 75206 Ph: 214-824-3333 Fax: 214-824-3131

Permission To Use And Disclose Protected Health Information

Under the Health Insurance Portability and Accountability Act of 1996, as amended, I understand that I have the right to determine whether or not I wish to have my protected health information (PHI) given out throughout the course of my treatment with Laila Hirjee, M.D. PA. The PHI listed in my medical records may include: my name, location, insurance information, a brief description of my medical condition (i.e., course of treatment, physician visits, medications, prescriptions, diagnostic testing and results, referral’s for miscellaneous

specialists, Home Health Agency Information, DME paperwork, past history, etc.) I understand that I have the right to ask that such information not be given to other non-medical entities or family members or anyone other than myself. I have indicated my choice below.

□ I DO wish my information to be given when questioned to other non-medical entities, family members, or anyone pertaining to that need per my doctor’s request.

□ I DO NOT wish my information to be given to anyone.

Printed Name_______________________________________________________________________________

Patient Signature________________________________________________________ Date_______________

Relationship if not patient_____________________________________________________________________

Patient’s Date of Birth______________________________ Patient’s SS#______________________________

Patient’s Address____________________________________________________________________________

If option can only be communicated orally by patient, then show it was recorded by:

Printed Name__________________________________________________ Phone______________________

Signature______________________________________________________ Date_______________________

Department/Title____________________________________________________________________________

Laila Hirjee, M.D. P A 5617 Belmont Ave Suite 103-D Dallas, Tx 75206 Ph: 214-824-3333 Fax: 214-824-3131

DNR

Are You A DNR □ Yes □ No

Living Will

Do You Have A Living Will □ Yes □ No

Advanced Directives

Would you like more information □ Yes □ No

regarding Advanced Directives?

_____________________________________________________________ ________________________Printed Name Date

_____________________________________________________________ ________________________Signature Date

Laila Hirjee, M.D. PA

5617 Belmont Ave Suite 103 D Dallas Tx 75206Phone 214.824.3333 Fax 214.824.3131

I acknowledge that I have received a copy of the above Laila Hirjee, M.D. P A HIPAA Notification of Privacy Practices and understand it’s contents therein.

_____________________________________________ _________________Patient Name (Printed) Date

_____________________________________________ _________________Patient Signature Date

5617 Belmont Ave Suite 103-D Dallas, Tx 75206 Phone: 214-824-3333 Fax: 214-824-3131

Laila Hirjee, M.D. 5 6 1 7 B e l m o n t Ave S u i t e 1 0 3 - D D a l l a s, Tx 7 5 2 0 6 P h o n e : 2 1 4 – 8 2 4 – 3 3 3 3 Fax: : 2 1 4 - 8 2 4 - 3 1 3 1

Board Certification:

1997 Board Certified Internal Medicine

Professional Experience

2004 – Current Private Practice – Internal Medicine2003 – 2004 Doctor’s Home Visits 1998-2002 Joel Wilkerson, M.D. Private Practice Internal Medicine Washington, D.C.

1997 – 1998 Fellow, Nephrology N.Y.U. Medical Center New York, NY

1995 – 1997 Resident, Internal Medicine (Chief Resident) Sisters of Charity Hospital Buffalo, NY

1994 – 1995 Resident, Internal Medicine St. Luke’s Hospital – Roosevelt Division Manhattan, NY

1992 – 1994 Medical Officer P.I.M.S Islamabad, Pakistan

1991 – 1990 M.B., B.S. (Bachelor of Medicine & Bachelor of Surgery Dow Medical College Karachi, Pakistan

Honors & Awards

1990 Graduated top 3%1990 13th Position (top 1 percentile) on first M.B.B.S. exam1990 Placed in First Division (Grade A)1990 Top 10% throughout Academic Career

Hospital Privileges

LakePointe Medical Center Select Specialty Hospital

Licensure & Certification

Licensed Physician – State of TexasLicensed Physician – District of ColumbiaBLS & ACLS

Curriculum Vitae

Board Certified – Internal Medicine

Membership & American Medical AssociationAssociations American College of Physicians

Texas Medical AssociationMetropolitan Who’s Who Association

LakePointe Medical Center 2007 Circle of Excellence

Personal Date of Birth: October 30, 1966 Gender: Female Marital Status: Married Hobbies: Movies, Music and Reading

References: Excellent References Available Upon Request

Laila Hirjee, M.D. PA

5617 Belmont Ave Suite 103 D Dallas Tx 75206Phone 214.824.3333 Fax 214.824.3131

Home Health Agency Preferred ProviderConsent Form

Please check the box that applies best for you.

If in the event that the patient needs home health

I prefer _________________________________home health agency if I / family member needs home health.

I prefer for Dr. Hirjee / Facility to send whichever home health agency that will best match my / family members home health needs.

________________________________________________ Printed Name

________________________________________________ Signature Date

Laila Hirjee, M.D. P AMedical History

PAST MEDICAL HISTORY Do you now or have YOU ever had any of the following illness, CHECK ALL THAT APPLYCANCER_____Colon Cancer_____Esophageal Cancer_____Stomach Cancer_____Breast Cancer_____Pancreatic Cancer_____Endometrial Cancer_____Liver Cancer_____Leukemia_____LymphomaOther_____________________________

LIVER_____Cirrhosis_____Hepatitis A_____ Hepatitis B_____ Hepatitis C_____Jaundice_____Fatty Liver

Other_____________________________

NEUROLOGICAL_____Stroke_____Seizures_____ Migraines_____ Other Headache

Other_____________________________RENAL_____Kidney Stones_____Kidney Failure_____Dialysis

Other_____________________________

PSYCHOLOGICAL_____Bipolar_____Anxiety_____Depression_____Obsessive Compulsive Disorder_____SchizophreniaOther_____________________________

HEART_____High Blood Pressure (Hypertension)_____Heart Attack_____Angina_____Congestive Heart Failure_____Premature Heart Disease_____Palpitations_____Mitral Valve Prolapse_____Elevated Cholesterol_____Rheumatic Fever_____Heart Valve Disease_____EndocarditisOther_____________________________

RESPIRATORY_____COPD (Emphysema)_____Asthma_____Tuberculosis (TB)_____Sleep Apnea_____Collapsed LungOther_______________________________

ENDOCRINOLOGY_____Diabetes, Type I (insulin needed)_____ Diabetes, Type II (pills needed)_____Thyroid Disease_____Hypothyroid_____HyperthyroidOther_____________________________

MUSCULOSKELETAL_____Fibromyalgia_____OsteoArthritis_____Rheumatoid Arthritis_____Raynaud’s_____Lupus_____Scleroderma_____GoutOther_____________________________

BLOOD_____VonWillebrands’_____Hemophillia_____Bleeding or clotting abnormalitiesOther____________________________

INTEGUMENTARY_____Eczema_____Skin Cancer_____Melanoma_____Psoriasis

Other_____________________________

GASTROINTESTINAL_____IBS – Irritable Bowel Syndrome_____Diverticulitis_____Diverticulosis_____Peptic Ulcer Disease_____Angiodysplasia of GI tract_____Gallstones_____Hoarseness_____Reflux Esophagitis_____IBD-Chrohn’s_____IBD-Ulcerative Colitis_____PancreatitisOther______________________________

PAST SURGICAL HISTORY Please Indicate The Year of any surgeries you have hadGASTROINTESTINAL_____Appendectomy_____Hiatal Hernia Repair_____Gallbladder Removal_____Exploratory Surgery_____Gastric Bypass_____Colon Resection, partial_____Colon Resection, complete_____Splenectomy

GYNECOLOGICAL_____Vaginal Hysterectomy_____Abdominal Hysterectomy_____Ovary Removal_____C-Section_____Breast Biopsy_____Mastectomy - Right/Left/Bi-LateralOther_____________________________

CARDIAC_____Heart Stent Placed_____CABG_____Abdomianl Aneurysm repair_____FemPop Bypas (Leg Arteries)_____Heart Valve ReplacementOther___________________________

_____Ventral Hernia_____Incisional Hernia_____Colonoscopy_____Upper Endoscopy_____ERCP_____WhippleOther_____________________________

GU_____TURP_____Bladder Surgery_____Inguinal Hernia_____Cystectomy with Ileal conduit_____Kidney Removal_____Prostate Removal_____Radiation for prostate cancerOther_____________________________

OTHER_____Hip Replacement __R __L_____Thyroidectomy_____Tonsillectomy_____Glaucoma Surgery_____Cataract Surgery_____Laser Surgery

Other___________________________

Laila Hirjee, M.D. P AMedication History

Please list ALL Medications you are currently taking. Even over the counter medications.

Medication Name Dosage Times/Day Comments

Alzheimer’s in the Elderly By: Laila Hirjee, M.D. PA

Everyday tasks becoming a problem? Are you having trouble recalling words, concentrating, naming objects, understanding commands, performing familiar actions such as word recognition or comprehending speech? These are just some of the signs to look for. Did you know that Alzheimer’s disease is one of the most common medical diseases in the elderly today? Causing cognitive impairment and a decline in mental status, it puts a substantial financial as well as mental burden on families across our country. Although the diagnosis of Alzheimer’s disease is often missed or delayed, the diagnosis can usually be made using standardized clinical criteria. In most cases it can be diagnosed and managed in primary care settings such as in the home or Assisted Living Facilities. Alzheimer’s disease is progressive and irreversible, but prescription drug therapies for cognitive impairment and for the behavioral problems associated with dementia can help to enhance a patient’s quality of life. Psychological therapy intervention with family members can also be beneficial when indicated, as nearly half of all caregivers themselves become depressed when dealing with a family member with Alzheimer’s. New breakthrough medical treatments and pharmacological advances are being made every day to ensure that patients have the very best chances of living their lives more independently, healthier and longer than ever before. If you or someone you know thinks you may have the signs of Alzheimer’s, please make an appointment with your physician today. It could make a world of difference to the ones you love. My goal as a physician is to maintain the very best quality of life for a patient and I strive to do my best to reach that goal with every patient I meet.

Board Certified In Internal Medicine

YOUR YEARS ”

GOALS

Maximize quality of life

Maintain resident’s health

Minimize hospital visits

Minimize number of falls

Maintain positive communication with resident & family

SERVICES OFFERED

In Home Podiatry

In Home Mobile Lab and X-ray

Cardiovascular Testing

Skilled Nursing, Physical Therapy

Occupational Therapy & Much More…

5617 Belmont Ave Suite 103-D Dallas, TX 75206 Phone: 214.824.3333 Fax: 214.824.3131