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James Moody, M.D. Nimesh H. Patel, M.D. Richard Meyrat, M.D. C. Benjamin Newman, M.D. Michael C. Oh, M.D.

PATIENT INFORMATION (Please Print) Workers Comp: អ Yes អ No

Co-Pay $ Name:

Date of Birth: (Last)

(First)

Address: Sex: អ M អ F

Age:

(Initial)

City:

State:

Zip:

State:

Zip:

Marital Status: អ S អ M អ D អ W

Ethnicity: អ Hispanic អ Latino អ Not Hispanic or Latino E-mail Address:

Soc. Sec. #:

Home Phone:

Cell Phone:

Employer:

Work Phone:

Employer Address: Emergency Contact Person:

City: Relation:

Referring Doctor:

Phone:

Primary Care Doctor:

Phone:

Cardiologist:

Phone:

Phone:

Billing Information Primary Insurance Company: Primary Insured Name: Secondary Insurance Company: Primary Insured Name:

Policy #: Relationship to Patient: Policy #: Relationship to Patient:

Group #: DOB: Group #: DOB:

1411 Beckley Ave., Pav. III, Suite 152, Dallas, TX 75203 ɍ (214) 948-2076 ɍ Fax (214) 948-9990

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Methodist Moody Brain and Spine Institute www.methodisthealthsystem.org/ brainandspine

1. Assignment of Benefits: Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, coinsurance, or any other balance not paid for by your insurance. IN ORDER TO CONTROL YOUR COST OF BILLINGS, WE REQUEST THAT OUR CHARGES FOR OFFICE VISITS ARE PAID PRIOR TO YOUR VISIT WITH THE PHYSICIAN. If this account is assigned to an attorney for collection and/or suit, the prevailing party shall be entitled to reasonable attorney’s fees for cost of collection. I understand that I am responsible for providing MMBSI all insurance information at the time of registration to allow for verification of benefits, and that regardless of my assigned insurance benefits, I am responsible for the total charges for services rendered. I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled including Medicare, private insurance, and other health plans to MMBSI. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information necessary to secure payment. ___________________________________ Acknowledgement Signature 2. Medicare Patients Only Medicare Assignment of Benefits: I certify that the information given by me in applying for payment under Title XVII of the Social Security Act is correct. I authorize the release of information concerning me to the Social Security Administration or its intermediaries or carriers as well as any information needed for filing a Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign benefits payable for services to the physician or organization submitting a claim to Medicare for me. Initial _________ Medicaid Patients Only Medicaid Assignment of Benefits: I understand that Medicaid recipients are responsible for payment of any medical care or services received that is beyond the amount, duration and/or scope of the Texas Medicaid Program, as determined by the Medicaid Department of its health insuring agency. All payments for non-covered services are due and payable prior to your visit with the physician.

(214) 948-2076 Phone (214) 948-9990 Fax PROVIDERS Richard B. Meyrat, MD James A. Moody, MD C. Benjamin Newman, MD Michael C. Oh, MD Nimesh H. Patel, MD Vanessa Bludau, FNP Stacey Castellanos, FNP Natalie Clarke, FNP Zanieb Shams, FNP LOCATIONS Addison 17101 North Dallas Parkway Addison, TX 75001 Dallas 1411 N. Beckley Ave Pavilion III, Suite 152 Dallas, TX 75203 Southwest Dallas / Duncanville 3430 Wheatland Rd Professional Building I, Suite 216 Dallas, TX 75237 Richardson 399 W. Campbell Road, Suite 400 Richardson, TX 75080 Mansfield 2800 E. Broad Street Professional Building, Suite 514 Mansfield, TX 76063 Sunnyvale / Mesquite 341 Wheatfield Dr, Suite 100 Sunnyvale, TX 75182 CONDITIONS / DISORDERS Acoustic Neuroma Aneurysm Arteriovenous Malformation (AVM) Back and Leg Pain Brain Tumors Brain Injury/Skull Fractures Carpal Tunnel Syndrome Cerebrovascular Disorders Nerve Disorders Pituitary Tumors Scoliosis Spinal Cord Injury/Fractures Spinal Disorders Spinal Tumors Radiosurgery Trauma Trigeminal Neuralgia

Initial _________

1411 Beckley Ave., Pav. III, Suite 152, Dallas, TX 75203 ɍ (214) 948-2076 ɍ Fax (214) 948-9990

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Methodist Moody Brain and Spine Institute www.methodisthealthsystem.org/ brainandspine

Patient Acknowledgement of Receipt of Privacy Notice, Financial Policy and Patient Rights The Methodist Moody Brain and Spine Institute (MMBSI) Notice of Privacy Practices (the “Notice”) Provides information about how MMBSI may use and disclose protected health information about you. You have the right to review the Notice before signing this acknowledgement. A copy of the current Notice is posted in the waiting room. The Notice contains on the first page, in the top right hand corner, the effective date. As provided in our Notice, the terms of our Notice may change. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we are bound by our agreement. By signing this form, you acknowledge receipt of the MMBSI Privacy Notice, Financial Policy and Patient Rights and Responsibilities. _____________________________________ Signature (and relationship if not patient)

_____________________________________ Witness Date

Authorization to Release Information: I authorize Methodist Moody Brain and Spine Institute (MMBSI) to furnish requested information from the patient’s medical and other records to: (1) any insurance company or third party payer for purpose of obtaining payment on account of MMBSI, (2) the disability insurance company to expedite my claim (3) any other person(s) or entities financially responsible for the patient’s care or treatment, and (4) representatives of local, state, or federal agencies in accordance with law. Such information may include, but is not limited to, information concerning communicable disease such as Acquired Immune Deficiency Syndrome (“AIDS”). I authorize the release of information from or the review of the patient’s records for purpose of conducting medical audits, utilization reviews, or quality assurance reviews. Below is my list of people with whom I give permission to discuss my healthcare. This does not include doctors and Worker’s Compensation. Records are routinely released to referring physicians and adjusters with Worker’s Compensation. 1. ______________________________________________________________________________ 2. ______________________________________________________________________________ 3. ______________________________________________________________________________ 4. ______________________________________________________________________________ 5. ______________________________________________________________________________

(214) 948-2076 Phone (214) 948-9990 Fax PROVIDERS Richard B. Meyrat, MD James A. Moody, MD C. Benjamin Newman, MD Michael C. Oh, MD Nimesh H. Patel, MD Vanessa Bludau, FNP Stacey Castellanos, FNP Natalie Clarke, FNP Zanieb Shams, FNP LOCATIONS Addison 17101 North Dallas Parkway Addison, TX 75001 Dallas 1411 N. Beckley Ave Pavilion III, Suite 152 Dallas, TX 75203 Southwest Dallas / Duncanville 3430 Wheatland Rd Professional Building I, Suite 216 Dallas, TX 75237 Richardson 399 W. Campbell Road, Suite 400 Richardson, TX 75080 Mansfield 2800 E. Broad Street Professional Building, Suite 514 Mansfield, TX 76063 Sunnyvale / Mesquite 341 Wheatfield Dr, Suite 100 Sunnyvale, TX 75182 CONDITIONS / DISORDERS Acoustic Neuroma Aneurysm Arteriovenous Malformation (AVM) Back and Leg Pain Brain Tumors Brain Injury/Skull Fractures Carpal Tunnel Syndrome Cerebrovascular Disorders Nerve Disorders Pituitary Tumors Scoliosis Spinal Cord Injury/Fractures Spinal Disorders Spinal Tumors Radiosurgery Trauma Trigeminal Neuralgia

Do you have an Advance Directive? Living Will? (Please circle) Yes or No _____________________________________ Signature (and relationship if not patient)

_____________________________________ Date

1411 Beckley Ave., Pav. III, Suite 152, Dallas, TX 75203 ɍ (214) 948-2076 ɍ Fax (214) 948-9990

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Chief Complaint: (Reason for today’s visit)

General: Age: Hand: អ Right Handed អ Left Handed Race: អ Caucasian អ African-American អ Hispanic អ Asian Race: អ Latino អ Non Hispanic or Latino Sex: អ Male អ Female (អ Pregnant?) Other:

What tests or studies have you had? អ None អ X-Rays អ MRI អ Physical Therapy អ EMG អ Injections អ CT Scan អ Others

History of Present Illness: How long have you had pain in this location? Location of Pain / Problem: អ Head Pain ᔛ Right អ Neck Pain ᔛ Right អ Arm ᔛ Right អ Back Pain ᔛ Right អ Leg ᔛ Right អ Hip ᔛ Right អ Buttock ᔛ Right Please indicate the severity of your pain / problem: ᔛ0 ᔛ1 ᔛ2 ᔛ3 ᔛ4 ᔛ5 ᔛ6 No pain Moderate Pain

ᔛ Left ᔛ Left ᔛ Left ᔛ Left ᔛ Left ᔛ Left ᔛ Left

ᔛ7

ᔛ Both ᔛ Both ᔛ Both ᔛ Both ᔛ Both ᔛ Both ᔛ Both

ᔛ 8 ᔛ 9 ᔛ 10 Worst Possible Pain

Please check if any of the following are applicable អ Worse in the Morning អ Better in the Morning អ Worse at Night អ Better at Night អ Worse with Activity អ Better with Activity អ Worse Sitting អ Worse Standing អ Worse Walking អ Comes and goes អ Better when treated with Medications អ Same or Worse when treated with Medications អ Dizziness អ Headaches អ Locking អ Radiating Pain អ Stabbing Pain អ Lasts for a short period of time អ Lasts for a long period of time អ Wakefulness at Night អ Sleepy and Lethargic During the Day Please explain in more detail your history of present illness

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Medical History: អ Yes អ No Diabetes អ Yes អ No Bleeding Tendency អ Yes អ No Hypertension អ Yes អ No TB infection អ Yes អ No Cancer អ Yes អ No Liver disease / hepatitis អ Yes អ No Rheumatoid Disease អ Yes អ No Gastritis អ Yes អ No Heart Disease អ Yes អ No HIV / AIDS អ Yes អ No Stroke អ Yes អ No Hereditary defects អ Yes អ No Arthritis / gout អ Yes អ No Asthma អ Yes អ No Seizures Other Condition: Surgical History: Please list any surgeries, hospitalizations, trauma you have had. What year? Which hospital?

Medications: អ None List all medications (prescription, over the counter, herbal, etc.) Medication

Dose

Medication Allergies: អ None MEDICATION

REACTION

Frequency

Reason

Latex/Rubber/Tape:

អ Rash អ Other

Anesthetic អ Rash អ Nausea អ Diarrhea អ Vomiting អ Other Food Allergies/Reactions: Penicillin អ Rash អ Nausea អ Diarrhea អ Vomiting អ Wheezing អ Other ________________________________________ Iodine អ Rash អ Nausea អ Diarrhea អ Vomiting អ Wheezing អ Other ________________________________________ Sulfa អ Rash អ Nausea អ Diarrhea អ Vomiting អ Wheezing អ Other ________________________________________ Codeine អ Rash អ Nausea អ Diarrhea អ Vomiting អ Wheezing អ Other Other drug allergies/reaction: Social History: Occupation (Current or Past): ____________________________________ Work Status: អ Working អ Retired (Year Retired? ____________) អ On Leave Who is going to be looking after you? How many children do you have? Disability Status អ Not disabled អ Disabled អ Applying for disability Use of Alcohol: អ Never អ 1-5 weekly អ > 2 daily អ Quit (when? ) Use of Tobacco: អ Never អ Occasional (packs/day? ) អ Quit (when? ) Use of Drugs: អ Never អ Occasional អ Frequent Type of drug Family History: អ Yes អ No Diabetes អ Yes អ No Bleeding Tendency អ Yes អ No Hypertension អ Yes អ No TB infection អ Yes អ No Cancer អ Yes អ No Liver disease / hepatitis អ Yes អ No Rheumatoid Disease អ Yes អ No Gastritis អ Yes អ No Heart Disease អ Yes អ No HIV / AIDS អ Yes អ No Stroke អ Yes អ No Hereditary defects អ Yes អ No Arthritis / gout អ Yes អ No Asthma អ Yes អ No Seizures Other Condition: 1411 Beckley Ave., Pav. III, Suite 152, Dallas, TX 75203 ɍ (214) 948-2076 ɍ Fax (214) 948-9990

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Review of Systems Please check the box(es) if you currently have any of these symptoms

* Musculoskeletal អ No Symptoms អ Yes អ No Swelling of Limbs អ Yes អ No Masses in Limbs អ Yes អ No Loss of Control of Arms or Legs Eyes អ No Symptoms អ Yes អ No Loss of Muscle Bulk អ Yes អ No Poor vision អ Yes អ No Aching Joints អ Yes អ No Blurry vision អ Yes អ No Neck Pain អ Yes អ No Double vision អ Yes អ No Neck Spasm អ Yes អ No Cramps Ears, Nose, Mouth and Throat អ No Symptoms អ Yes អ No Weakness អ Yes អ No Loss of hearing អ Yes អ No Ringing in ears *Skin and Breast អ No Symptoms អ Yes អ No Dry Skin អ Yes អ No Decreased ability to smell អ Yes អ No Discharge From Nipples អ Yes អ No Difficulty swallowing អ Yes អ No Hoarseness *Neuro អ No Symptoms អ Yes អ No Slurred speech អ Yes អ No Dizziness អ Yes អ No Seizure Cardiovascular អ No Symptoms អ Yes អ No Shortness of Breath អ Yes អ No Abnormal Arm or អ Yes អ No Chest Pain Leg Sensations អ Yes អ No Irregular Heart Beat អ Yes អ No Arm or Leg Weakness អ Yes អ No Palpitations អ Yes អ No Poor Coordination អ Yes អ No Numbness Respiratory អ No Symptoms អ Yes អ No Tingling អ Yes អ No Chronic Cough អ Yes អ No Loss of Sensation អ Yes អ No Coughing Blood អ Yes អ No Emphysema * Psychiatric / Emotional អ No Symptoms អ Yes អ No Anxiety អ Yes អ No Bronchitis អ Yes អ No Disorientation អ Yes អ No Asthma អ Yes អ No Depression អ Yes អ No Hallucinations Genito-Urinary អ No Symptoms អ Yes អ No Burning on Urination * Endocrine អ No Symptoms អ Yes អ No Poor Appetite អ Yes អ No Dark or Discolored Urine អ Yes អ No Cold Intolerance អ Yes អ No Difficulty Starting or អ Yes អ No Excessive Thirst Ending Stream អ Yes អ No Loss of Body Hair អ Yes អ No Poor Control of Bladder អ Yes អ No Weight Gain of Greater អ Yes អ No Excessive Thirst than 20 pounds អ Yes អ No Sexual Dysfunction អ Yes អ No Weight Loss of Greater អ Yes អ No Inability to obtain / than 20 pounds maintain erection អ Yes អ No Easy Fatigue Gastro-intestinal អ No Symptoms *Hematology / Lymphatic អ No Symptoms អ Yes អ No Weight loss អ Yes អ No Bleeding, Clotting or Any អ Yes អ No Blood in Stool Other Blood Disorders អ Yes អ No Dark Colored Stool អ Yes អ No Abdominal Pain * Allergic / Immunologic អ No Symptoms អ Yes អ No Hernia អ Yes អ No Allergic to inhaled pollen, etc. អ Yes អ No Difficulty Swallowing អ Yes អ No Decreased immune អ Yes អ No Nausea system response អ Yes អ No Vomiting អ Yes អ No AIDS អ Yes អ No Abdominal Swelling អ Yes អ No Diarrhea អ Yes អ No Constipation អ Yes អ No Abdominal Mass 1411 Beckley Ave., Pav. III, Suite 152, Dallas, TX 75203 ɍ (214) 948-2076 ɍ Fax (214) 948-9990 General អ Yes អ Yes អ Yes

អ No Symptoms អ No Fever អ No Night Sweat អ No Weight Loss

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Where is your pain now? Mark the areas on your body where you feel the described sensations. Please use the appropriate symbol(s) to show the type of pain and include all affected areas. Numbness II II II II

Pins and Needles 00000

Burning xxxxx

Stabbing

Ache

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1411 Beckley Ave., Pav. III, Suite 152, Dallas, TX 75203 ɍ (214) 948-2076 ɍ Fax (214) 948-9990 POS® Reorder # 0926863