1. UNIVERSITY DIAGNOSTIC TREATMENT CLINICS Date:_________Patient Name:_____________________________________________________Date of Birth:_______________ Last First All questions contained in this questionnaire are strictly confidential and will become part of your medical record. Please list all prescriptions, vitamins, herbs, and over-the-counter medications that you are currently taking and/or bring your Medications with you to your appointment. (If additional space is needed please copy this page) MedicationsStrengthDoseHow many times a day **Allergies** Medication ( Include prescription, over –the-counter and /or vitamins) Describe reaction Have you ever had an allergic reaction to: Contrast Dye Iodine Shell Fish What type of reaction did you have: Hives Shortness of breath Other: _________________ _________________________________________________________________________________________ **Pharmacy Information** ___________________________________________________ ( ) __________________________ Pharmacy Name Phone number ___________________________________________________________________________________________________ Address City State Zip Code

2. UNIVERSITY DIAGNOSTIC TREATMENT CLINICS Date:_________Patient Name:_____________________________________________________Date of Birth:_______________ Last First Have you ever had any of the following symptoms or diseases?: Seizures Yes / NoThyroid Disease Yes / No Tuberculosis Yes / NoShortness of Breath Yes / No Asthma Yes / NoHeart Attack Yes / No Heart Failure Yes / NoChest Pain Yes / No Heart Murmur Yes / NoHigh Blood Pressure Yes / No Breast Mass/Cyst Yes / NoStomach/intestinal ulcers Yes / No Bleeding Disorder Yes / NoDiabetes Yes / No Bladder Infections Yes / NoVaginal Infections Yes / No Kidney Stones Yes / NoArthritis Yes / No Blood clots in legs Yes / NoHepatitis Yes / No Cancer Yes / NoBlood in Urine Yes / No Blood in stool Yes / NoFrequent urination Yes / No Diarrhea Yes / NoConstipation Yes / No Change in stools Yes / No Black tarry stools Yes / No Change in weight Yes / NoSwelling in legs/feet Yes / No Has anyone in your family ever had any of the following diseases? If yes, list their relationship to you: Uterine Cancer: __________________________________________________________ Cervical Cancer: __________________________________________________________ Ovarian Cancer: __________________________________________________________ Breast Cancer: ___________________________________________________________ Colon Cancer: ____________________________________________________________ Prostate Cancer: __________________________________________________________ High blood pressure: _______________________________________________________ Diabetes: ________________________________________________________________ Is there anything else in your health history that you feel I should know?: ____________________________ ______________________________________________________________________________________ List any surgeries, the date, and hospital where the surgery was performed: Date:Surgery Type:Hospital:Notes:

3. UNIVERSITY DIAGNOSTIC TREATMENT CLINICS Date:_________Patient Name:_____________________________________________________Date of Birth:_______________ Last First Review of Symptoms General ___Weight loss/gain ___Energy Level ___Fatigue ___Poor Appetite ___Night Sweats Digestion ___Nausea ___Heartburn ___Indigestion ___Vomitting ___Diarrhea ___Constipation ___Hemorrhoids ___Bleeding ___Black Stools ___Other Gento-Urinary System ___Burning ___Dark or bloody urine ___Stones ___Infection ___Colonoscopy ___Constipation Respirations ___Cough ___With sputum ___With blood ___Chest pain ___Wheezing ___Other Cardiovascular ___Chest pain with effort ___Cholesterol ___Heart Problems ___Hypertension ___Shortness of Breath ___Heart Attack ___Stroke ___Angina Eyes ___Blurred vision ___Double vision ___Cataracts ___Glaucoma ___Spots ___Other Ear, Nose & Throat ___Poor hearing ___Ringing in ears ___Hearing Aid ___Nose Bleeds ___Stuffy Nose ___Sinusitis ___Difficulty Chewing Food ___Difficulty Swallowing ___Dentures ___Hoarseness Women ___Irregular periods ___Missed periods ___Hot flashes ___Last pap smear ___Last mammogram Men ___Prostate problems ___Last prostate exam ___Last PSA test ___How many times do you urinate at night ___Other Joints and Muscles ___Joint pain ___Back pain ___Swollen joints, where _____________________ ___Other Skin ___Itching ___Rash ___Sores ___Other Emotional Status ___Nervous ___Tearful ___Depressed ___Change in sleeping pattern ___Other Pain ___Severity-1, 2, 3, 4, 5, 6, 7, 8, 9, 10 ___Location____________________ ___Duration____________________ ___What makes it: ___Better______________________ ___Worse_____________________ ___________________________________________________________________________________________ Patient Signature Date Reviewed with patient by: __________________________________________________________________________________________ Physician Signature Date

4. UNIVERSITY DIAGNOSTIC TREATMENT CLINICS Date:_________Patient Name:_____________________________________________________Date of Birth:_______________ Last First PATIENT CONFIDENTIALITY QUESTIONAIRE 1.Please list the family members or other persons, if any, that we may inform about your general medical condition and your diagnosis: Name:__________________________ Phone:______________________________ 2.Please list the family members or significant other, if any, that we may inform about your medical condition ONLY IN AN EMERGENCY: Name:__________________________ Phone:______________________________ 3.Please print where you would prefer to have your billing statement and/or correspondence from our office sent if other than your home address: Address:________________________________________________________________ City:_______________________________State:_____________Zip Code:___________ 4.Please print the name of the person (if other than self) and phone number where you would like to receive phone calls concerning your appointments, labs, radiology results, or other health information if other than your home phone number. Name:___________________________ Number:________________________________ Can confidential messages (i.e. appointment reminders) be left on your telephone answering machine? Yes_______ No________ ___________________________________________ _______________________ Patient/Guardian Signature Date

5. UNIVERSITY DIAGNOSTIC TREATMENT CLINICS INDIVIDUALS YOU DO NOT WANT INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE Patient Name:______________________________________________________________________ Patient Acct.#:______________________________________________________________________ Date of Birth:_______________________________________________________________________ According to our Notice of Privacy Practices, we may release your health information, including information about your condition to a family member or friend who is involved in your medical care or who helps you pay for your car. If you would like us to refrain from releasing your health information to a family member or friend, please list the name(s) of who you DO NOT want your private health information released to on the lines below. Remember, in the future, if there are additions to this list, please notify the University Cancer Diagnostic and Treatment Clinics staff. This authorization will remain in effect until revoked by you in writing. Thank you. Name:_____________________________________________________________________________ _________________________________________________ ____________________ Patient Signature Date

6. UNIVERSITY DIAGNOSTIC TREATMENT CLINICS Dear Patient, Welcome to University Cancer Diagnostic and Treatment Clinics. We appreciate the opportunity to provide you with the highest quality care available. If you have any questions or concerns, ask and we will do our best to give you a response as quickly as possible. Also attached are: a Patient Confidentiality Questionaire for you to tell us who, if anyone, you would like to have access to your confidential records a Medical History Questionaire for you to tell us about your past and present health and an Assignment of Benefits form for you to provide us information concerning issures about financial responsibility of your services Please review and complete all attached forms to the best of your ability and bring with you to your appointment or hand in to front desk. To avoid scheduling delays and ensure that we can correctly assess your condition, please ask your referring physician to provide us with all necessary medical records, pathology reports and insurance referral forms (if applicable) prior to your appointment. Again, if at any time you have questions, concerns or problems let us know. We will make every effort to address your situation in the most satisfactory manner as possible. Sincerely, University Cancer Diagnostic and Treatment Clinics Beamer 12811 Beamer Rd Houston, TX 77089 Phone: 713-474-1414 Fax: 713-474-8477 Pasadena 4135 Spencer Highway Pasadena, TX 77504 Phone: 713-474-1414 Fax: 713-474-8477 North Houston 1900 North Loop West, #310 Houston, TX 77018 Phone: 713-474-1414 Fax: 713-474-8477 Houston Heights 2724 Yale St Houston, TX 77008 Phone: 713-474-1414 Fax: 713-474-8477