630 S. Raymond Ave., Suite 104 Pasadena, CA 91105 Tel: (626) 768-1021 Fax: (626) 768-1022 www.pasadenacyberknife.

com

NEW PATIENT QUESTIONNAIRE Patient Name: ___________________________ Date: _________________

Welcome to the Pasadena CyberKnife Center! We hope the time you spend with us will be helpful, informative and healing. Please take the time to answer the following questions so that our physician will be able to evaluate your health concerns thoroughly. PHYSICIAN CONTACTS Name Primary Care Physician Address Telephone Fax Number

Medical Oncologist

Address

Telephone

Fax Number

Surgeon

Address

Telephone

Fax Number

Other Physicians

Address

Telephone

Fax Number

630 S. Raymond Ave., Suite 104 Pasadena, CA 91105 Tel: (626) 768-1021 Fax: (626) 768-1022 www.pasadenacyberknife.com

Patient Name: ________________________________ SURGERY Check any major surgeries you have undergone, along with the appropriate year they were performed. Check Below Procedure Appendectomy Tonsillectomy Cesarean Section delivery Hysterectomy Other: Other: Other: Do you have any of the following illnesses or medical problems? Illness or medical conditions High Blood Pressure Diabetes (High blood sugar) Heart Disease (chest pain, heart attack) Asthma or emphysema Stomach ulcers or gastritis Rheumatoid arthritis Internal diverticulosis Lupus or scleroderma Autoimmune or connective tissue disease Year

Yes

No

Please list any other major illnesses (requiring a hospital stay or regular visits to your physician): __________________________________________________________________ ____________________________________________________________________________ MEDICATIONS List all medications that you are presently taking. Name of the medication Amount you take daily

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630 S. Raymond Ave., Suite 104 Pasadena, CA 91105 Tel: (626) 768-1021 Fax: (626) 768-1022 www.pasadenacyberknife.com

Patient Name: _________________________________ ALLERGIES If you have any known allergies to medications, foods or other substances, please list them below and briefly explain your reaction. Allergic to: My reaction:

Tell us about your teeth: Do you wear dentures? ___ No ___ Yes How is your dental health? ___ Excellent ___ Good ___ Poor HABITS Tobacco: Do you smoke? ___ No ___ Yes Number of cigarettes/cigars per day: _________________________ Number of year you have smoked: ___________________________ If you have quit smoking, how along ago: ______________________ Do you use chew or snuff? ___ No ___ Yes For how long? _______ Alcohol: Do you drink alcoholic beverages? ___ No ___ Yes How many drinks per day? ____________ Do you ever drink heavily? (More than 2-3 drinks daily) ___ No ___ Yes For how many years? __________ Caffeine: Do you drink coffee, tea or colas? ___ No ___ Yes How many cups/cans per day? ___________ FOR WOMEN ONLY Number or pregnancies: ___________________ Number of children: _________________ Age at first period: ________________________ Age at first pregnancy: _______________ Have you ever used birth control pills? ___ No ___ Yes (if No, you do not need to complete the remainders of this section) Age at last period: ________________________ Have you ever taken estrogen or other hormone replacement therapy? ___ No ___ Yes If yes, for how many years? ________________ Page 3

630 S. Raymond Ave., Suite 104 Pasadena, CA 91105 Tel: (626) 768-1021 Fax: (626) 768-1022 www.pasadenacyberknife.com

Patient Name: _______________________________ LIVING SITUATION AND SOCIAL FACTORS Who lives with you? (Spouse/children/parents/etc.) __________________________________ What is your occupation? _______________________________________________________ Who provides assistance and emotional support for you during this illness? (please check any that apply) Spouse Family Friends Church Group

Therapist Cancer Support Group Social Worker

Family History: Please list any of your blood relatives who have had cancer. If you know the kind of cancer (breast, prostate, colon, lung, etc) list this also. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ REVIEW OF SYMPTOMS Check any of the following symptoms that you have experienced in the past few months. SYMPTOM CHECK SYPMTOM CHECK HERE HERE
CONSTITUTIONAL: GASTROINTESTINAL

Weight Loss (more then 5 pounds) Fever / Chills Night sweats Aches and Pains EYES AND ENT: (ears, nose, and throat) Headache Double Vision Sore Throat Hearing problems
RESPIRATORY:

Nausea Vomiting Constipation Diarrhea Bloody or dark stool

GENITOURINARY

Blood in Urine Urinary Frequency Difficulty in urination Getting up at night to urinate

NEUROLOGICAL Weakness

Shortness of breath Coughing up blood Phlegm

CARDIOVASCULAR:

Numbness Dizziness or balance problems.

Chest pain Palpitation We appreciate you taking the time to complete these questions. This will assist us in providing you with excellent care. Page 4

630 S. Raymond Ave., Suite 104 Pasadena, CA 91105 Tel: (626) 768-1021 Fax: (626) 768-1022 www.pasadenacyberknife.com

Consent for Purpose of Treatment, Payment, and Health Care Operations

I consent to the use or disclosure of my protected health information (PHI) by Albert C. Mak, M.D.,INC. for the purpose of diagnosing or providing treatment to me, obtaining payment for my imaging services or to conduct health care operations of Albert C. Mak, M.D.,INC. I understand that diagnosis or treatment of me by a Albert C. Mak, M.D.,INC. physician or any of their agents may be conditioned upon my consent as evidenced by my signature on this document. I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment, or health care operations of the practice. Albert C. Mak, M.D.,INC. is not required to agree to the restrictions that I may request. However, if Albert C. Mak, M.D.,INC. agrees to the restrictions that I request, the restriction is binding on Albert C. Mak, M.D.,INC. I have the right to revoke this consent, in writing, at anytime, except to the extent that Albert C. Mak, M.D.,INC. has taken in reliance on this consent. My Protected Health Information means health information, including my demographic information collected from me and created or received by my referring physician, another health care provider, a health plan, my employer, or a health care clearinghouse. This protected health care information relates to my past, present or future physical or mental health or condition and identifies and identifies me or there is a reasonable basis to believe the information may identify me. I understand I have the right to review Albert C. Mak, M.D.,INC. Centers Notice of Privacy Practices prior to signing this document. Albert C. Mak, M.D.,INC. Centers Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health care information that will occur in my treatment, payment of my bills or in the performance of health care operations of Albert C. Mak, M.D.,INC. The Notice of Privacy Practices for this imaging center is available in the lobby of this office. Albert C. Mak, M.D.,INC. reserves the right to change the privacy practices that are described in the Notices of Privacy Practices. I may obtain a revised notice of privacy by calling this office and requesting a revised copy be sent in the mail or requesting for at the time of my next appointment. ____________________________________
Patient Signature

____________________________________
Patient Name-PRINTED

____________________________________
Legal guardian or Patients Personal Representative

_________________ Relationship to Patient Page 5

____________ Date

630 S. Raymond Ave., Suite 104 Pasadena, CA 91105 Tel: (626) 768-1021 Fax: (626) 768-1022 www.pasadenacyberknife.com

Financial Policy
The physicians at Albert C. Mak, M.D.,INC. Radiation Oncology center are committed to providing you with the best possible medical care, and are pleased to discuss our professional fees and Financial Policy. Your clear understanding of our Financial Policy is important to our professional relationship. All Patients must complete our Patient Information Form before being seen by the doctor and this form must be updated at least once a year Cash patients will need to pay in full at the time of service The payment of any deductible or co-payment is due at the time of service The payment of the balance of any insurance charges that are more than 90 days from the date of service are also due immediately and at the time of any subsequent service We accept cash, check, MasterCard or Visa A $25.00 fee will be charged for all returned checks ADULT PATIENTS Adult patients are ultimately responsible for payment for all medical services. MINORS ACCOMPANIED BY AN ADULT The parents or legal guardians of minors are ultimately responsible for payment for all medical services. REGARDING INSURANCE We will bill your insurance as a courtesy to you, and we will make every legal and ethical attempt to maximize your insurance benefits. But you must be responsible for any deductibles, copayments, denied or non covered services. We cannot accept your insurance payment as payment in full. If after 90 days from the date of service we are unable to obtain payment from your insurance company then you will be responsible for payment in full. Initials_____ Medical insurance is a contract between you and your insurance company. We will not become involved in disputes between you and your insurance company regarding deductibles, co-payments, non covered charges, secondary insurance etc., other than to supply factual information as necessary. While we know you have to make many decisions regarding medical care, we hope that the quality of service our physicians are determined to provide will be worth the investment that you make in your health care. If there are any changes made to your Health Coverage/Medical insurance during the course of your treatment, all unpaid claims will become your total financial responsibility. Initials______ I have read and understood all the above mentioned terms of this Financial Policy ___________________________________ Signature of Patient /Legal Guardian ___________________________________ Responsible Party to Patient ___________________________________ Translator Date: _____________________________

Date: _____________________________

Date: _____________________________

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630 S. Raymond Ave., Suite 104 Pasadena, CA 91105 Tel: (626) 768-1021 Fax: (626) 768-1022 www.pasadenacyberknife.com

Patient Name:______________________________________ DOB:_____________________________________________

CT SCAN QUESTIONARIE
1. Are you diabetic? YES NO

2.

Do you have kidney problems?

YES

NO

3.

Have you had an allergic reaction to IV contrast?

YES

NO

4.

Are you allergic to seafood?

YES

NO

5.

Do you have asthma? YES *If you have asthma, bring your inhaler the day of your CT exam. Do you take Metformin or Glucophage? YES *If you do take Meftormin or Gucophage: DO NOT take your Metformin or Glucophage on the day of your CT scan and up to 48 hours after the exam. ***FOR PHYSICIANS USE ONLY*** IV contrast contraindicated? YES

NO

6.

NO

NO

Per review of form by:

Dr. Albert C. Mak Dr. Sara Kim

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