SUNSHINE MEDICAL CENTER, LLC PATIENT INFORMATION FORM 5937 Beneva Road Sarasota, FL 34238

PATIENT INFORMATION

Patient Name Date of Birth Age

Street Address

City, State and Zip Code

Home Phone Work Phone

Soc. Sec. # Marital Status Allergies

Driver's License # Cell phone #

Patient's Employer

Spouse's Name Spouse's Work #

Spouse's Employer

Emergency Contact: Relationship

Address: Phone # ( )

Referred by (how you heard about us)

BILLING INFORMATION & RESPONSIBILITY

Billing Name Relationship (If other than patient)

Billing Address

INSURANCE INFORMATION

Nome of insured Relationship to Patient

Primary Insurance Co. Phone #

ID# Group

Additional insurance Co. Phone #

ID Group #

Note: Payment expected at time of service, unless prior arrangements made

Signature Date

SUNSHINE MEDICAL CENTER, LLC MEDICATIONS FORM 5937 Beneva Road Sarasota, FL 34238

Name

Date

Medicine Strength(mg) AM Noon PM Bed PRN

© DATAMED FORMS AND SOFTWARE, INC. .

List All Illnesses, Injuries & Operations

Date Hospital Treatment Physician Response

Immunizations/Vaccinations/Dates ! DPT __ /___/___ ! Measles___/___/___ ! Mumps___/___/___ !Pneumoccocal___/___/___ ! Smallpox___/___/___ ! Influenza___/___/___ ! Typhoid ___/___/___ ! Polio___/___/____ ! Tetanus ___/___/___ ! MMR___/___/___

Blood Type ! A + ! A - ! B + ! B - ! AB + ! AB - ! O - ! O + ! Other: _____________

Blood Transfusions No. of Transfusions: ________________ Date(s) __________________________ Reason(s) _______________________________ _________________________________ _________________________________

Last Chest X-Ray : ___________ !Normal !Abnormal Last TB Skin Test: ____________ !Positive !Abnormal Last EKG: ___________________ Last Eye Exam: _______________

List ALL Allergies Allergic Reaction

List Blood Relatives Health Status Age If Living Age At Death Cause Of Death Illnesses Father

Mother

Brother(s)

Sister(s)

Allergies - List your allergies including any medications that caused an allergic reaction.

Past Medical History - Please provide a complete a history including all illnesses, injuries, hospitalizations and operations.

Family History- Please list all Blood Relatives with their current health status and any illnesses they have had or have.

Mental Work: ! Omit ! Light ! Moderate ! Heavy Hours Per Day: ______ Physical Work: ! Omit ! Light ! Moderate ! Heavy Hours Per Day: ______ Exercise: ! Omit ! Light ! Moderate ! Heavy Hours Per Week: _____ Types Of Exercise:________________________________ __________________________________________________________________________________________________________________________ Alcohol: ! Omit ! Never ! Beer(s) _____ Per Week ! Liquor ______ Per Week ! ______ Wine Per Week How Many Years: _____ Smoking: ! Omit ! Never ! Current ! Previous Packs Per Day: ______ How Many Years: ______ ___ ______________________________________________________________________________________________________________________ Caffeine: ! Omit ! None Cups Per Day: ______ How Many Years: ______ Other: ________________________________ Aspirin: ! Omit ! None Quantity Per Day: _____ How Many Years: ______ Other: ________________________________ ______________________________________________________________________________________________________________ Nutritional Information: !Low Sodium Diet !Diabetic Diet !Low Fat Diet !Vegetarian Diet !Low Cholesterol Diet !Other: _____________ Miscellaneous Drugs: ! Amphetamines ! Antacids ! Cocaine ! Diet Pills ! Laxatives ! Marijuana ! Nutrasweet

! Pain Pills ! Saccharin ! Sleeping Pills ! Vitamins ! Other______________________________________

© DATAMED FORMS AND SOFTWARE, INC.

First Name:_______________________________________Middle:________________________Last Name:__________________________________

GENERAL ! WEAKNESS ! FATIGUE ! FEVER ! CHILLS ! NIGHT SWEATS ! FAINTING ! NONE

SKIN ! COLOR CHANGES ! NAIL CHANGES ! HAIR CHANGES ! MOLES ! RASHES ! ITCHING ! SORES ! DRYNESS ! NONE

HEAD ! HEADACHES ! INJURIES ! BUMPS ! NONE

EYES ! BLURRED VISION ! GLAUCOMA ! REDNESS ! ITCHING ! BURNING ! SWELLING ! PAIN ! DRYNESS ! TEARING ! NONE

EARS ! HARD OF HEARING ! DEAFNESS ! RINGING ! DISCHARGE ! EARACHE ! ITCHING ! LOSS OF BALANCE ! DIZZINESS ! ROOM SPINS ! NONE

NOSE ! DECREASED SMELL ! BLEEDING ! PAIN ! DISCHARGE ! OBSTRUCTION ! POST NASAL DRIP ! DEVIATED SEPTUM ! RUNNY NOSE ! SINUS CONGESTION ! NONE

MOUTH ! BLEEDING GUMS ! SORES ! DENTAL PROBLEMS ! PAIN ! BAD BREATH ! LOSS OF TASTE ! DRYNESS ! ULCERS ! BLISTERS ! BAD TASTE ! NONE:

THROAT ! SORE THROAT ! BAD TONSILS ! HOARSENESS ! PAIN ! HARD TO SWALLOW ! RECURRENT INFECTIONS ! WHITE SPOTS ! NONE

NECK ! ENLARGEMENT ! STIFFNESS ! SORENESS ! PAIN ! LUMPS ! MASSES ! NONE

BREASTS ! DISCHARGE ! NODULES ! PAIN/TENDERNESS ! CHANGES ! SKIN ! BLOATEDNESS ! MASSES ! BLEEDING ! NONE

LUNGS ! COUGH ! PHLEGM ! COUGHED BLOOD ! SHORTNESS OF BREATH ! WHEEZING ! PAIN IN LUNGS ! CHEST CONGESTION ! INHALANT EXPOSURE ! NONE

HEART ! MURMUR ! PALPITATIONS ! RAPID HEARTBEAT ! SWOLLEN EXTREMITIES ! COLD EXTREMITIES ! TIGHTNESS/PRESSURE ! CHEST PAINS ! VARICOSE VEINS ! BLOOD CLOTS ! BLUE EXTREMITIES ! NONE

BLOOD ! BROKEN BLOOD VESSELS ! ANEMIA ! EASY BRUISING ! PROLONGED BLEEDING ! SWOLLEN NODES ! PAINFUL NODES ! RED DOTS/SPOTS ! NONE

GASTROINTESTINAL ! ABDOMINAL PAIN ! NAUSEA ! VOMITING ! BLOATEDNESS ! BELCHING ! HEARTBURN ! INDIGESTION ! IRREGULAR BOWELS ! CONSTIPATION ! DIARRHEA

! GAS ! HEMORRHOIDS ! HERNIAS ! POOR APPETITE ! FOOD INTOLERANCE ! BLOODY STOOLS ! BLACK TARRY STOOLS ! EXCESSIVE APPETITE ! RECTAL BLEEDING ! NONE

GENITOURINARY ! URGENCY ! INCONTINENCE ! STRAINING ! FLANK PAIN ! FREQUENCY ! STONES ! BURNING ! BED WETTING ! BLOODY ! SMALL STREAM ! URETHRAL DISCHARGE ! DRIBBLING ! CLOUDY URINE ! UNUSUAL COLOR ! URINATION AT NIGHT ! HESITANCY ! NONE

GYNECOLOGICAL ! BREAKTHROUGH BLEEDING ! MENSTRUAL CRAMPS ! POST MENOPAUSAL ! VAGINAL DISCHARGE ! VAGINAL ITCHING ! LABIAL SORES ! LABIAL LUMPS/NODULES ! IRREGULAR MENSES ! PAINFUL INTERCOURSE ! HOT FLASHES ! PAIN BETWEEN MENSES ! LOSS OF LIBIDO ! MOOD SWINGS ! NIGHT SWEATS ! NONE

(GYN. DATES) MENSTRUAL FLOW ! LIGHT ! MODERATE ! HEAVY DATE OF LAST MENSES ____/____/____ LAST PAP SMEAR _____/______/_____ LAST MAMMOGRAM_____/_____/______ DURATION OF CYCLE______(21-30 DAYS) DURATION OF FLOW________(3-7 DAYS) AGE AT 1ST PERIOD__________________ AGE AT MENOPAUSE_________________ CONTRACEPTION ! NO ! YES TYPE- ___________________________ NO. OF PREGNANCIES _______________ NO. OF STILL BIRTHS________________ NO. OF LIVE BIRTHS_________________ NO. OF MISCARRIAGES_______________ NO. OF ABORTIONS_________________

MUSCULOSKELETAL ! PAIN ! WEAKNESS ! CRAMPS ! TWITCHING ! JOINT STIFFNESS ! JOINT PAIN ! JOINT SWELLING ! JOINT DEFORMITIES ! INJURIES ! CURVATURE OF SPINE ! BACK PAIN ! HOT JOINT ! NONE

NEUROLOGICAL ! SEIZURES ! VERTIGO ! HAND TREMBLING ! LOSS OF SENSATION ! INCOORDINATION ! LOSS OF FACIAL EXPRESSIONS ! WEAK GRIP ! PARALYSIS ! SLURRED SPEECH ! TINGLING/BURNING/NUMBING ! LOSS OF MEMORY ! LACK OF CONCENTRATION ! DISORIENTATION ! GAIT SHUFFLING ! NONE

PSYCHIATRIC ! HYPERVENTILATION ! INSECURITY ! DEPRESSION ! INSOMNIA ! IRRITABILITY ! ANXIOUSNESS/STRESS ! INDECISIVENESS ! TIMID/SHY/BASHFUL ! HALLUCINATIONS ! ALCOHOL ABUSE ! DRUG USE ! SUICIDAL THOUGHTS ! WORRYING ! OBSESSIVENESS ! MANIA/DEPRESSION

! MULTIPLE PERSONALITIES ! SEXUAL DIFFICULTIES ! NUMBNESS ! PANIC ATTACKS ! COMPULSIVENESS ! NONE

ENDOCRINE ! WEIGHT LOSS ! WEIGHT GAIN ! HOARSENESS ! HEAT INTOLERANCE ! COLD INTOLERANCE ! BREAST CHANGES ! LOSS OF HAIR ! EXTREME THIRST ! VOICE CHANGES ! EXCESSIVE HAIR ! HYPOGLYCEMIA ! DIABETES ! NONE

REVIEW OF SYMPTOMS - CHECK ONLY THE ONES YOU NOW HAVE OR HAVE HAD RECENTLY.

Vital Signs

Height: ____________ Method: ! Auricular ! Oral Weight: _____________ ! Axillary Temp: ______________ ! Forehead Resp: _______________ ! Rectal

B.P. Pulse Extremity Comment Sitting: __________ __________ __________ ______________________ Standing: __________ __________ __________ ______________________ Supine: __________ __________ __________ _______________________

SUNSHINE MEDICAL CENTER, LLC HIPAA DISCLOSURE FORM

Patient consent for use and disclosure of protected Health Information

With my consent, Sunshine Medical Center may use and disclose protected health information (PHI) about me

to carry out treatment, payment and healthcare operation (TPO). Please refer to Sunshine Medical Center’s

Notice of Privacy Practices for a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent. Sunshine Medical Center

reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may

be obtained by forwarding a written request to the Sunshine Medical Center Privacy Officer at 5937 Beneva

Road, Sarasota, FL 34238.

With my consent Sunshine Medical Center may call my home or other designated location and leave a message

on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as

appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results

among others.

With my consent, Sunshine Medical Center may mail to my home or other designated location any items that

assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as

they are marked personal and confidential. By signing this form, I am consenting to Sunshine Medical Center’s

use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the

practice has already made disclosures in reliance upon prior consent. If I do not sign this consent, Sunshine

Medical Center may decline to provide treatment to me.

Signature of patient or legal guardian

Patients Name

Print name of patient or legal guardian Date

SUNSHINE MEDICAL CENTER, LLC PAYMENT AUTHORIZATION FORM 5937 Beneva Road Sarasota, FL 34238

ASSIGNMENT OF INSURANCE BENEFITS I hereby authorize direct payment of surgical/medical benefits to Sunshine Medical Center LLC services rendered

by Dr. S. Prakash, in person or under his/her supervision, I understand that I am financially responsible for any

balance not covered by my insurance.

Signature of responsible party Date

AUTHORIZATION TO RELEASE INFORMATION I hereby authorize Dr. S. Prakash to release my medical or incidental information that may be necessary for

either medical care or in processing applications for financial benefits.

Signature of responsible party Date

I have received and read the Notice of Privacy Practices for sunshine Medical Center LLC.

Signature of responsible party Date

SUNSHINE MEDICAL CENTER, LLC LIVING WILL DECLARATION 5937 Beneva Road Sarasota, FL 34238

Declaration, made this ___________________ day of _______ , 2011, I, __________________________ willfully and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth below, and I do hereby declare: If at any lime should have a terminal condition and my attending or treating physician and another consulting physician have determined that there is no medical probability of my recovery from such condition, I direct that life-prolonging procedures be withheld or withdrawn, when the application of such procedures would serve only to prolong artificially the process of dying, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care or to alleviate pain. It is my intention that this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and to accept the consequences for such refusal. In the event that I have been determined to be unable to provide express and informed consent regarding the withholding, withdrawal or continuation of life-prolonging procedures, I wish to designate the following person as my surrogate to carry out the provisions of this declaration:

Print Name and signature

Address

Phone

I understand the full import of this declaration, and I am emotionally and, mentally competent to make this declarant.

Witness Witness

Address Address

Phone Phone

SUNSHINE MEDICAL CENTER, LLC AUTHORIZATION TO RELEASE INFORMATION 5937 Beneva Road Sarasota, FL 34238

Patient name

Address City

State Zip Phone #

Date of Birth SS#

I authorize my medical information to be released from:

Physicians name

Address City

State Zip Phone #

PLEASE MAIL OR FAX RECORDS TO: Sunshine Medical Center LLC Soordal Prakash M.D. & Shanthi Prakash M.D. 5937 Beneva Road Sarasota, Florida 34238 Office # 941-918-2011 / Fax # 941-918-2046

For the purpose of review/examination of medical history ________ Records from previous physicians (history, clinical, summary, recent labs, x-rays, surgeries) from the last three years. I understand that: This authorization expires one year from the date signed. I may revoke this consent by written statement at any time to extent that action has taken in reliance thereon. My treatment, payment, enrollment or eligibility for benefit may not be conditioned on signing this authorization, there is potential for re-disclosure by the recipient, and no longer protected.

Signed

Date

Witness

SUNSHINE MEDICAL CENTER, LLC OFFICE POLICY FORM 5937 Beneva Road Sarasota, FL 34238

I agree to abide by the following while I am under the medical care of Sunshine Medical Center: To keep the office informed of any changes in my address, phone numbers and insurance information, by calling with the new information or giving it to the front desk upon signing in. Patents under 18 must have a parent or guardian sign an authorization to be treated at each visit. For school age patients, a copy of their immunization record is to be given to the office. Whenever possible, contact the office for prescription renewals 7-10 days before medication runs out, and to call ahead before picking up written prescriptions. If for any reason you cannot make your scheduled appointment, please call our office 24 hours prior to cancelling your appointment otherwise you will be billed $25.00 for a missed appointment. For urgent medical care after hours or on weekends, call the office and leave a voice mail message including your name and phone number. The doctor will return your call promptly, so have your pharmacy phone number handy. For a true medical emergency, call 911 to be taken to Sarasota Memorial or Doctors Hospital emergency room and inform the ER of your doctor's name. The doctor will follow your hospital treatment. If you need to change doctors, the office has a written request form which must be completed. Your medical records will be copied and you may pick them up when ready or records may be faxed or mailed to the doctor whose name and address you have supplied to us. A charge may be applied. Medicare assignment of benefits is accepted. Regarding other insurance coverage, please check with the office. Be advised that deductibles and co-payments are your responsibility and are due at the time of service. Other (non-insurance) payment is due at the time of service. I have read and agree to abide by the policies written above.

Signed Date