Dear valued patient,

We are located at 146 Passion Play Rd., Ste A, Eureka Springs, AR 72632 (inside Eureka

Springs Family Clinic) Phone # for directions to Eureka Clinic: 479-253-9746.

Phone# for appointments, scheduling surgery, or medical questions: 479-521-3300.

Main office location: 3264 N. North Hills Blvd., Fayetteville, AR 72703

If you are unable to keep your appointment, please notify our office

at least 24-hours in advance 479-521-3300.

We reserve the right to charge a no-show or same-day cancellation fee of $45.

Please fill out the paperwork completely in the comfort of your home with your records and medications

readily available. Please do not mail back but bring to appointment.

Please note, our surgeons may be called away to surgery or delayed from surgery.

Please call ahead if driving far or unable to wait long.

Upon arrival, please give the receptionist the following:

* Your completed paperwork

* A list of current medications (or bring your medication bottles for nurse review)

* Driver’s License or Picture ID

* Insurance Card(s)

* Any co-pay, deductible, or amount not covered by insurance

To prepare for your visit:

* Please wear a face mask

* Prepare to wait in the foyer for COVID-19 screening

* If patient rooms are full, we may ask you to return to your vehicle and we will call when a

room is ready

* Visitor of patients permitted to enter the office only if medically necessary to assist with

care.

* No visitors under the age of 18 years old.

If you have new symptoms of persistent cough, shortness of breath, fever greater than 100.0, chills,

muscle pain, headache, sore throat, loss of taste/smell, or contact with anyone with a suspected or

confirmed case of Coronavirus please call to reschedule this appointment and go to the nearest

Washington Regional COVID-19 testing facility by calling the screening hotline 479-463-2055.

If you have any questions or need directions, please contact our office. We look forward to your visit.

Sincerely,

Management

NAME : ______________________________________________________________________ BIRTHDATE: ________________________

ADDRESS: _______________________________________________________________________ SSN: _______________________________

IF PO BOX, 911 ADDRESS: ________________________________________________________________________________________________

HOME PH# ______________________________________________________ CELL PH#: ____________________________________________

EMAIL ADDRESS: _____________________________________________________________ MARITAL STATUS: ____________________

CONTACT PREFERENCE: □ BY PHONE □ BY EMAIL □ BY PHONE & EMAIL □ DO NOT CONTACT (may need to complete a separate form)

EMPLOYER NAME: ___________________________________________________________ EMPLOYER PH#: ____________________________

EMPLOYMENT: □ FULL TIME □ PART TIME □ NOT EMPLOYED □ SELF EMPLOYED □ RETIRED □ ACTIVE MILITARY

OCCUPATION: _________________________________ IF RETIRED, RETIRE DATE: _____________________ VETERAN: □ YES □ NO

RACE: □WHITE □AFRICAN AMERICAN □ASIAN □NATIVE HAWAIIAN/PACIFIC ISLANDER □ AMERICAN INDIAN/ALASKAN □HISPANIC □UNKNOWN □DECLINE

ETHNICITY (ORIGIN): □ NOT HISPANIC OR LATINO □ HISPANIC OR LATINO □ UNKNOWN □ DECLINE

1. NAME RELATIONSHIP PHONE

ADDRESS

EMPLOYMENT: □ FULL TIME □ PART TIME □ NOT EMPLOYED □ SELF EMPLOYED □ RETIRED □ ACTIVE MILITARY

OCCUPATION: _________________________________ IF RETIRED, RETIRE DATE: _____________________ VETERAN: □ YES □ NO

2. NAME RELATIONSHIP PHONE

ADDRESS

EMPLOYMENT: □ FULL TIME □ PART TIME □ NOT EMPLOYED □ SELF EMPLOYED □ RETIRED □ ACTIVE MILITARY

OCCUPATION: _________________________________ IF RETIRED, RETIRE DATE: _____________________ VETERAN: □ YES □ NO

PRIMARY CARE PHYSICIAN NAME: PHONE

ADDRESS:

SECONDARY CARE PHYSICIAN NAME: SPECIALITY:

ADDRESS & PHONE NUMBER:

NAME: PHONE

ADDRESS:

MAIL-ORDER PHARMACY NAME:

MAIL-ORDER PHARMACY ADDRESS:

SIGNATURE: ____________________________________________________________________________________________________________ Date: ____________________________

if indicated (note: CDs will become patient records and not subject to return). Co-pay & co-insurance due at the time of appointment

DR. JEFFREY BELL

DR. JON BERRY

DR. GARETH ECK

DR. STEPHEN WOOD

BRITTANY HULS, APRN

In order to protect your privacy, Cardiovascular and Thoracic Surgery Clinic asks you to list the family member, friends or any person(s) (including but not limited to spouses, significant others, and legal representatives ) who we may contact or can request or inquire regarding your Protected Health Information which includes medical condition and/or billing and financial information.

EMERGENCY CONTACTS

Please bring the following to your appointment: Insurance cards & picture I.D, all medications or a list of medications, CD of testing

PHARMACY

PHYSICIAN CARE TEAM

Please bring your medications, or a list of them, to your office visit and ask your doctor to write refills for any medications you anticipate needing.

Patients who have been seen by the doctor at appropriate intervals may call for refills on some prescriptions (antibiotics excluded). You may call your pharmacy 2 - 3 days

prior to running out of medication so the pharmacy can fax a refill request to the clinic. Please allow 48 hours for refill requests. Requests received after 2 p.m. will be not be

reviewed until the next business day. No pain medication prescriptions will be written on Friday. Most pain medication prescriptions will require the patient or

respresentative to pick up from our office. Please bring a photo ID at the time of pick up.

GENDER: □ MALE □ FEMALE □ NEUTRAL □ BORN MALE/CURRENT FEMALE □ BORN FEMALE/CURRENT MALE

Reviewed by/Credentials: _________________________________________ Date: __________________

NAME: ___________________________________________________________ DOB: _________________ REASON FOR VISIT: ______________________________ HEIGHT: _____________ WEIGHT: ______________

FLU VACCINE THIS YEAR YES NO – IF YES, WHO ADMINISTERED VACCINE: ___________________

PAST MEDICAL HISTORY: Arthritis Diabetes High Blood Pressure Prostate Problem

Asthma Emphysema High Cholesterol Rheumatic Fever

Atrial Fibrillation Fibromyalgia HIV Positive Seizures

Bleeding Disorders Glaucoma Kidney Disease Stroke

Bronchitis Gout Liver Disease Thyroid Problems

Cancer Heart Attack Pacemaker Tuberculosis

Congestive Heart Failure Hepatitis Pneumonia Ulcers

Other____________________________________________________________________________________________________

PAST SURGICAL HISTORY:

OPERATION WHEN AND WHERE OPERATION WHEN AND WHERE

Have you had a colonoscopy? YES NO Date performed: __________________ Normal? YES NO Any polyps? YES NO Explain: _________________________________________________________________ MEDICATIONS: (Please list all your medications including inhalers, as well as vitamin and herb supplements.) IF MORE LINES NEEDED, ADD SEPARATE PAGE PLEASE DO NOT FORGET TO LIST ALL BLOOD THINNERS

NAME DOSE HOW OFTEN PER DAY PRESCRIBED BY

11

22

33

44

55

66

77

88

99

1100

ALLERGIES: (Please list all of your allergies or write “No Known Allergies”.)

MEDICATION REACTION LAST ONSET MEDICATION REACTION LAST ONSET 11 55

22 66

33 77

44 88

FOOD:

OTHER:

Reviewed by/Credentials: _________________________________________ Date: __________________

NAME: ___________________________________________________________ DOB: _________________

SOCIAL HISTORY: Married, Widowed, Single or Divorced (circle one) Number of children:_______ Age(s) of Child(ren): ________________ Who lives in your home? _____________________________________________________________________________________

Do you smoke? Yes_____ No_____ How much?_____________________________________________________

(circle) Tobacco, E-cigarettes, Cigars, Pipe How often?_____________________________________________________

Chewing Tobacco or Vape Nicotine% ______ How long?______________________________________________________

Did you ever smoke? Yes_____ No_____ When did you quit?_______________________________________________

(circle) Tobacco, E-cigarettes, Cigars, Pipe How much?_____________________________________________________

Chewing Tobacco or Vape Nicotine% ______ How long?______________________________________________________

Do you drink alcohol? Yes_____ No_____ If yes, how much?__________how often?________ (circle) beer, wine, liquor

Do you use illegal drugs? Yes_____ No_____ If so, what kind?_________________________________________________

Are you concerned that you may have been exposed to HIV? Yes_________ No__________

(circle one) Employed, Unemployed, Retired, Disabled

What type of work do you currently do/retired from? _____________________________________________________________

Religious Preference? ______________________ Highest Level of Education? ________________________________________

Native Language? _________________________ Amount of family or social support? (Good/Poor/None) __________________

FAMILY HISTORY: Member Age State of Health Age at Death Cause

Father ______ ____________ __________ _________________________________________________________________ Mother ______ ___________ __________ _________________________________________________________________ Brothers ______ ____________ __________ _________________________________________________________________ ______ ____________ __________ _________________________________________________________________ Sisters ______ ____________ __________ _________________________________________________________________ ______ ____________ __________ _________________________________________________________________

Do you have an Advance Directive or Living Will? YES, I have a Living Will on file YES, I have an Advance Directive on file NO, I don’t have either Prefer not to disclose

If you have a Living Will or Advance Directive, is it current? YES NO A healthcare proxy is a person you have appointed to make healthcare decisions for you if you lose the ability to make decisions for yourself. By appointing a healthcare agent, you can make sure that healthcare providers follow your wishes. Do you have a healthcare proxy? YES NO Relation: __________________________________________________ Healthcare proxy’s: Full Name: ___________________________________________________________ As of date: _____________ Phone Number(s): _________________________ Address: _________________________ City/State/Zip: _____________________ HIPAA Disclosure Information: Authorization by: Patient or Legal Guardian (Name): ___________________________

The physician/practice may use or disclose the following protected health information: Any and all Excepted from disclosure: __________________________________________________________________________ Disclosure of health information (select all): Any healthcare provider/facility OK to leave voicemail

Names/relation of authorized people: ________________________________ ________________________________

______________________________________________ _________________________________________________

Patient signature: ____________________________________________________ Date: ____________________

Patient Name: _____________________________________ DOB: _______________ Please mark “Y” for yes or “N” for no if you recently have any of the following:

Constitutional: Reproductive:

□ Y □ N Fever □ Y □ N Breast lump □ Y □ N Fatigue (tiredness) □ Y □ N Breast pain □ Y □ N Recent (unintentional )Weight Loss (____ lbs) □ Y □ N Nipple pain

□ Y □ N Recent Weight Gain (____ lbs)

□ Y □ N Not feeling well Metabolic/Endocrine:

□ Y □ N Chills □ Y □ N Cold intolerance

□ Y □ N Heat intolerance

Dermatologic:

□ Y □ N Rash Ulcer Neurological:

□ Y □ N Ulcer □ Y □ N Headache

□ Y □ N Memory impairment

HEENT: □ Y □ N Dizziness

□ Y □ N Vision changes □ Y □ N Seizures

□ Y □ N Hearing loss □ Y □ N Extremity numbness

□ Y □ N Nasal drainage □ Y □ N Extremity weakness

Respiratory: Psychiatric:

□ Y □ N Acute Cough □ Y □ N Anxiety

□ Y □ N Shortness of breath □ Y □ N Depression

□ Y □ N Wheezing □ Y □ N Insomnia

Cardiovascular: Integumentary:

□ Y □ N Chest Pain □ Y □ N Hair loss

□ Y □ N Palpitations □ Y □ N Hives

□ Y □ N Edema (swelling) □ Y □ N Rash

□ Y □ N Skin lesion

Gastrointestinal: □ Y □ N Pruritis (itching)

□ Y □ N Abdominal Pain

□ Y □ N Blood in Stools Musculoskeletal:

□ Y □ N Constipation □ Y □ N Back pain

□ Y □ N Diarrhea □ Y □ N Joint pain

□ Y □ N Heartburn □ Y □ N Joint swelling

□ Y □ N Nausea □ Y □ N Muscle weakness

□ Y □ N Vomiting □ Y □ N Neck pain

Genitourinary: __________________________

□ Y □ N Polyuria (excessive urine output) (Patient signature)

□ Y □ N Urinary frequency

□ Y □ N Urinary incontinence (loss of control) __________________________

(Today’s date)