Pulmonary Hypertension Center at

Oklahoma Heart Hospital New Patient History Form

Confidential Record: Information contained here will not be released unless you have authorized us to do so. Please fill out form the best you can. Name

Age DOB Today’s Date

What doctor referred you to our clinic? Dr. If not referred by a physician, how did you hear about us? Primary Care Physician and Phone number? Dr. What are your current symptoms? (Check all that apply)

Shortness of breath Chest Pain or Tightness Chest pain Abdominal swelling or bloating Racing Heart or Palpitations Feeling more tired than you should be Leg Swelling Lightheaded with activity Passing out or feeling like you’re about to pass out

Do you currently have or have you ever been diagnosed with any of the following medical conditions?

High Blood Pressure (Hypertension) Scleroderma Coronary Artery Disease, Heart Attack or Heart Stent Lupus Congestive Heart Failure Rheumatoid Arthritis Lung Disease (circle) Asthma, COPD, Interstitial Lung

Disease, Pulmonary Fibrosis, Sarcoidosis, Other Mixed Connective Tissue Disease

Obstructive Sleep Apnea (OSA) HIV or AIDS Blood Clot in your leg (Deep vein thrombosis, DVT) Blood clot in your lung (Pulmonary embolus, PE) Liver disease or Cirrhosis of the Liver Sickle Cell Anemia Hemolytic Anemia

Have you ever taken any of the following medications or drugs?

Aminorex (Menacil or Apiquel) Fenfluramine (Fen-Phen, Pondimin, Adifax, or Pondirax) Dexfenfluramine (Redux) Benfluorex (Mediator) Medications for Depression or Anxiety St John’s Wort Tryptophan Rapeseed Oil Interferon alpha or beta

Please list medications you are currently taking, including over the counter medicines (or attach a list). Name, dose, and frequency 1. 7. 2. 8. 3. 9. 4. 10. 5. 11. 6. 12.

OHHP-F581A (N. 11/14)

ist any allergies or adverse reactions to medications No Allergies

1. 3. 2. 4.

ocial History Are you: employed retired disabled at-home spouse/parent What is/was your occupation?

Have you ever used illicit drugs? Yes No Have you ever injected drugs? Yes No

Have you ever smoked cigarettes? Yes No Have you ever used Methamphetamine(Meth)? Yes NoHave you ever used cocaine? Yes No

If yes, how many cigarettes/day (on average)? Do you drink alcohol? Yes No For how many years? How many drinks/week? Are you still smoking? Yes No

amily History

Is there anyone in your family who has ever been diagnosed with pulmonary hypertension? Yes No Please list any known health problems with family members Mother- Father- Siblings- Children- Others-

pworth leepiness cale How likely are you to fall asleep or doze in the circumstances listed below? When rating these situations, give the highest consideration to recent events. If you have never experienced one of the situations, estimate how you might have reacted.

No chance light chance oderate chance High Chance ituation Chance of Dozing ( )

Sitting and reading Watching television Sitting inactive in a public place (ie theater or meeting) As a passenger in a car for an hour without a break Lying down to rest in the afternoon Sitting and talking quietly with someone Sitting quietly after lunch (without alcohol) In a car, while stopped for a few minutes in traffic

ist any surgeries procedures and dates

/

Birds in the home? Yes No Mold in the home? Yes No Chemical Exposure? Yes No

Hot tub or sauna? Yes No Feather bedding? Yes No Asbestos exposure? Yes No Mine worker? Yes No

Are you married? Yes No Living arrangements?

OHHP-F581B (N. 11/14)

Review of ystems Constitutional es No Cardiovascular es No Do you often feel tired or worn out? Do you have frequent fevers or chills?

Do you have pain, tightness or pressure in your chest?

If yes, is it only with activity? Has your weight changed (lost or gained) by more than 5 pounds in the last year?

Do you have night sweats? Does your heart ever beat so fast it feels like it’s racing or beating out of your chest?

Do you have swelling of your feet or ankles? yes Do you frequently feel bloated ?

Have you had a change in your vision recently? Do you have blurry or double vision?

Has your waist size increased due to swelling of your abdomen?

N astrointestinal

Do you have: Do you have: Dry mouth? Heartburn or indigestion after meals? Trouble hearing? Poor appetite? Frequent or severe nosebleeds? Frequent nausea or vomiting? Frequent nasal congestion or stuffiness? Pain with swallowing? Ringing or buzzing in your ears? Sensation of food getting ‘stuck’ in your Sore throat? throat while swallowing? Constipation? Respiratory Diarrhea? Are you short of breath with: Blood in your stools? Resting or sitting comfortably?

Central Nervous ystem Getting ready for your day? (Bathing, Putting on your clothes, preparing a meal)

Do you have frequent or severe headaches?

Going up one or two flights of stairs? Walking at your own pace on level ground?

Do you have episodes where you feel the room is spinning?

Walking briskly, running, or working out? Lying flat?

Have you recently fainted, passed out, or almost passed out?

Do you sleep in a recliner or with multiple pillows at night?

Do you have numbness or tingling in your head, arms or legs?

Do you have problems with seizures? Are you short of breath with bending over to tie your shoes or to pick something up?

Do you consider yourself a nervous person?

Do you have a frequent cough? Do you struggle with feeling depressed? Do you ever cough up blood? Have you lost a desire to do things you

normally enjoy?

Do you have panic attacks? usculoskeletal

Do you have joint pain or stiffness? Women nly If so, where? Do you still have menstrual cycles? Do your fingers or toes turn bluish or white when they get cold? (Raynaud’s)

Do you have muscle weakness?

Do you take medication or have an internal device to prevent pregnancy? (Diaphragm, IUD, etc)

Do you have significant pain that would prevent you from walking at your own pace for 5-6 minutes?

Have you had surgery that would prevent pregnancy? (Hysterectomy, tubes tied, etc.)

OHHP-F581 (N. 11/14) OriginalForm Revision # Form Changes

PLEASE PRINTPATIENT INFORMATION

If this is work-related, stop and notify receptionist.Date Referring Physician & Phone Number Family Physician & Phone Number OHHP Physician & Phone Number

LEGAL NAME Last Suffix First Middle Sex

‘ M ‘ F

Preferred Name

Address City State Zip

Country Home Telephone( )

Age Birthdate / /

Marital Status: S M W D DEP

SS# – –

Race: ‘ African American‘ Asian ‘ Caucasian‘ Hispanic ‘ Native American‘ Pacific Islander ‘ Other

Ethnicity:‘ Hispanic or Latino‘ Non-Hispanic or

Non-Latino

Religion: Language:‘ English‘ Spanish‘ Other

Interpreter needed?

‘ Yes ‘ No

Employer Address City State Zip

Employment Status: Full-time Full-time student Not employed Military Part-time Part-time student Retired Self-employed

Business Phone & Ext.( )

Cell Phone Pager E-Mail May we contact youthrough email?Yes No

Patient’s Primary Contact (Other than Spouse not living in the same residence) Contact’s DOB Relationship to Patient

Home Phone( )

Work Phone & Ext.( )

Cell Phone

SPOUSE/PARENT INFORMATIONSpouse/Parent Spouse or parent information (if child under 18) Relation to Patient Home Telephone

( )Cell Phone

Employment Status: Full-time Full-time student Not employed Military Part-time Part-time student Retired Self-employed

Employer SS# – –

Birthdate Age Work Phone & Ext.( )

Address City State Zip

INSURANCE INFORMATION (Provide cards to copy)Do you have Health Insurance Coverage? Yes or No (If yes, please complete the primary and secondary info below.)Primary Insurance Insurance Type

‘ Group ‘ Individual ‘ Cobra

Insured’s Name on Card I.D. # Group #

Insured’s Birthdate

/ /

Patient Relation to Insured Insured’s Sex Insured’s SS#– –

‘ Self ‘ Spouse ‘ Child ‘ Other ‘ M ‘ F

Secondary Insurance Insurance Type

‘ Group ‘ Individual ‘ Cobra

Insured’s Name on Card I.D. # Group #

Insured’s Birthdate

/ /

Patient Relation to Insured Insured’s Sex Insured’s SS#– –

‘ Self ‘ Spouse ‘ Child ‘ Other ‘ M ‘ F

OTHER INFORMATIONI authorize the release of medical information required to process all claims on my behalf. I also authorize payment of insurancebenefits from those claims be made payable to: OKLAHOMA HEART HOSPITAL PHYSICIANS. I understand I am financiallyresponsible for any charges not covered by my insurance.

PATIENT OR AUTHORIZED PERSON DATE

Form Revision # Form Changes

OHHP-F67PB (Rev. 2/13)

OHHP-F67PB (Rev. 6/17)

Home Phone

Relationship to Paitent

Next of Kin (NOK)

Emergency Contact (EMC) Contact’s DOB

Contact’s DOB Relationship to Paitent

Home Phone

Work Phone & Ext.

Work Phone & Ext.

Cell Phone

Cell Phone( )

( )

( )

( )

( )

( )

Revision table added

NOK & ER contact

CONDITIONS OF ADMISSION Medical and Surgical Consent: The patient, or his or her representative, hereby acknowledges the patient’s need for hospitalization or treatment because he or she suffers from a condition requiring diagnosis and medical and/or surgical treatment. The undersigned requests and voluntarily consents to the patient’s receipt of the usual Hospital services, as well as the diagnostic laboratory (such as testing of the blood and other bodily fluids), x-ray procedures, medical and/or surgical treatment, including administration of anesthesia judged to be necessary by the patient’s attending physician, his assistants or other physicians designated by him. The Hospital is authorized to retain, preserve and use for scientific or teaching purposes, or dispose of at its convenience any specimens or tissue removed from the patient’s body during hospitalization or treatment. Assignment of Insurance Benefits: I hereby authorize payments from all insurance companies to be made directly to OKLAHOMA HEART HOSPITAL and/or Oklahoma Heart Hospital Physicians for benefits otherwise payable to me. I understand that I am financially responsible to the hospital for charges not covered by this assignment. I certify that the above information in support of this claim is true and correct. Payment Responsibility: The undersigned understands that the patient, or another person who specifically agrees to guarantee payment for the patient, is responsible for the payment of all charges of the Hospital or Physician relating to services rendered by the Hospital or Physician to the patient that exceed any third party coverage, including applicable coinsurance payments and deductibles and all amounts for which payment has been denied by any third party. There are other services that will be billed separately from the hospital bill including services performed by other physician specialists who perform services for your care and treatment while a patient at Oklahoma Heart Hospital. Amounts due from the patient to the Hospital prior to execution of this Agreement may, at the sole discretion of the Hospital, be consolidated with, and made a part of, the amount due hereunder. The patient shall pay all costs of collection in connection with the enforcement of this commitment, including reasonable attorney’s fees and court costs incurred by the Hospital. You authorize personal contact from us or our third party collector, via telephone or cell phone numbers provided to us, including line voice, text, auto dialed or prerecorded message. Other Uses of PHI: I understand that in-hospital staff committees may utilize data relating to my condition in the course of studies for the purpose of advancing medical research or medical education in the interest of reducing morbidity or mortality. I understand that should the recipients use or publish such information or material that my identity shall be confidential and shall not be revealed under any circumstances. Provider Based Billing: When seeing an OHH healthcare provider for any type of outpatient services, you will see a change in the way you are billed. Under “Provider Based” status, OHH is required to bill provider services in two parts. When your medical services are completed, OHHP will submit a claim for the professional fee and OHH will submit a claim for the facility fee. You will receive two statements/bills for your services – one from Oklahoma Heart Hospital and one from Oklahoma Heart Hospital Physicians. N/A ________ (Initial) I acknowledge receipt of the Provider Based Medicare Outpatient Coinsurance Notice; actual liability will depend on services furnished. N/A Notification of HIV Testing: The undersigned has been notified of the testing of the patient’s blood for human immunodeficiency virus (also known as AIDS) if determined by the patient’s attending physician. This is necessary (i) for determining the appropriate treatment and/or treatment procedures for the patient or (ii) for the protection of the attending physician and/or any employee or agent of the Hospital or the attending physician exposed to the bodily fluids of the patient in a manner which could transmit such disease. __________ (Initial) Facility Directory: Unless I object, I understand that my name, location, general condition, and religious affiliations may be released to the clergy or to others who ask for me by name. Agree Object (If I object, I understand I cannot receive phone calls, deliveries, etc.) ________ (Initial) Acknowledgment of Notice of Privacy Practices: I have received/reviewed the “Notice of Privacy Practices” from Oklahoma Heart Hospital. If I have any questions, I know to contact the Privacy Officer whose information is provided to me in the “Notice of Privacy Practices”. I understand that if I request a copy of this form one will be provided to me by the Registration staff. _________ (Initial) Disclosure of Physician Interest: The Oklahoma Heart Hospital has financial relationships with a number of Oklahoma physicians, some of whom have an ownership interest in the Hospital, and some of whom are paid by the Hospital for services they provide. If the physician who recommended the Hospital to you has a financial interest, and if his or her financial relationship with the Hospital concerns you, you may be treated at an alternative facility, if there is one available. If you would like to discuss your options for treatment at other facilities, or if you have any questions about this disclosure, please ask the person providing you with this form for assistance. A list of physician owners has been provided to me. _________ (Initial) THE UNDERSIGNED CERTIFIES THAT HE HAS READ THE FOREGOING AND IS THE PATIENT, OR IS DULY AUTHORIZED BY THE PATIENT AS PATIENT’S GENERAL AGENT TO EXECUTE THE ABOVE AND ACCEPTS ITS TERMS. ___________________________ Date Patient, Patient’s Agent or Representative __________________________ __________________________________________________ Witness Agent or Representative’s Relationship to patient

Date & Version # Change Summary 11/24/2015 Ver 4 Multiple Changes 02/24/2017 Ver 5 Multiple Changes

Patient Name:______________________________________ Admission Date:____________________________________ MRN:____________________________________________

OHHP-F437

Stop!

If you are on Medicare or 65 years of age or older, please complete

the next form.

If you are not on Medicare and less than 65 years of age, please stop

here.

Patient Name:______________________________________ Admission Date:______________DOB:_________________

MSP Questionnaire

PART I

1. Are you currently enrolled in a SNF or Hospice facility? � Yes. What is the name, address and phone number of the facility? Name: _______________________Address: _______________________________________Phone:____________________

_______________________________________ � No.

2. Are you receiving Black Lung (BL) Benefits? � Yes. Date benefits began: ____/____/____ MM/DD/YY (Staff only: BL IS PRIMARY ONLY FOR CLAIMS RELATED TO BL.) � No.

3. Are the services to be paid by a government research program? � Yes. (Staff only: GOVERNMENT PROGRAMS WILL PAY PRIMARY BENEFITS FOR THESE SERVICES.) � No.

4. Has the Department of Veterans Affairs (DVA) authorized and agreed to pay for care at this facility? � Yes. (Staff only: DVA IS PRIMARY FOR THESE SERVICES.) � No.

5. Was the illness/injury due to a work-related accident/condition? � Yes. Date of injury/illness: ____/____/____ MM/DD/YY

Patient: IF YES, GO TO PART III AND CONTINUE. (Staff only: WC IS PRIMARY PAYER ONLY FOR CLAIMS RELATED TO WORK RELATED INJURIES OR ILLNESS.)

� No.

PART II

1. Was the illness/injury related to a non-work related accident? � Yes. Date of injury/illness: ____/____/____ MM/DD/YY � No. Patient: IF NO, GO TO PART III.

2. Is no-fault insurance available? � Yes. Patient: IF YES, GO TO PART III AND CONTINUE.

(Staff only: WE DO NOT FILE NO-FAULT INSURANCE. PATIENT WILL BE SELF PAY.) � No.

3. Is liability insurance available? � Yes. (Staff only: WE DO NOT FILE LIABILITY INSURANCE. PATIENT WILL BE SELF PAY.) � No.

2

Patient Name:______________________________________

PART III

1. Are you entitled to Medicare based on: � Age Patient: COMPLETE PART IV ONLY. � Disability Patient: COMPLETE PART V ONLY. � End-Stage Renal Disease (ESRD) Patient: COMPLETE PART VI ONLY.

PART IV - Age

1. Are you currently employed? � Yes. � No. � No, never employed. � No, retired. Date of retirement: ____/____/____ MM/DD/YY

2. Is your spouse currently employed? � Yes. � No. � No, never employed. � No, retired. Date of retirement: ____/____/____ MM/DD/YY Patient: IF NO TO BOTH QUESTIONS 1 AND 2, STOP. DO NOT PROCEED. (Staff: MEDICARE IS PRIMARY.) Patient: IF YES TO QUESTIONS 1 AND 2, CONTINUE.

3. Do you have a Group Health Plan (GHP) coverage based on your own or your spouse’s current/former employment? � Yes, both. � Yes, self. � Yes, spouse. � No.

4. Are you covered under the Group Health Plan (GHP) of a family member other than your spouse? � Yes. � No. (Staff: MEDICARE IS PRIMARY PAYER UNLESS ANSWERED YES TO THE QUESTIONS 1 OR 2.)

5. Does the employer that sponsors the patient’s Group Health Plan (GHP) employ 20 or more employees? � Yes. (Staff: GROUP HEALTH PLAN IS PRIMARY.) � No. (Staff: MEDICARE IS PRIMARY PAYER UNLESS ANSWERED YES TO THE QUESTIONS 1 OR 2.)

6. Does the employer that sponsors your Group Health Plan (GHP) employ 100 or more employees? � Yes. (Staff: GROUP HEALTH PLAN IS PRIMARY.) � No. (Staff: MEDICARE IS PRIMARY PAYER UNLESS THE PATIENT ANSWERED YES TO THE

QUESTIONS 1 OR 2.)

3

Patient Name:______________________________________

PART V - Disability

1. Are you currently employed?

� Yes. � No. � No, never employed. � No, retired. Date of retirement: ____/____/____ MM/DD/YY

2. Do you have a spouse who is currently employed? � Yes. � No. � No, never employed. � No, retired. Date of retirement: ____/____/____ MM/DD/YY Patient: IF NO TO BOTH QUESTIONS 1 AND 2, STOP. DO NOT PROCEED. (Staff: MEDICARE IS PRIMARY.) Patient: IF YES TO QUESTIONS 1 AND 2, CONTINUE.

3. Do you have a Group Health Plan (GHP) coverage based on your own or your spouse’s current/former employment? � Yes, both. � Yes, self. � Yes, spouse. � No.

4. Are you covered under the Group Health Plan (GHP) of a family member other than your spouse?

� Yes. � No. (Staff: MEDICARE IS PRIMARY PAYER UNLESS ANSWERED YES TO THE QUESTIONS IN PART I

OR II.)

5. Does the employer that sponsors the patient’s Group Health Plan (GHP) employ 20 or more employees? � Yes. (Staff: GROUP HEALTH PLAN IS PRIMARY.) � No. (Staff: MEDICARE IS PRIMARY PAYER UNLESS ANSWERED YES TO THE QUESTIONS IN PART I

OR II.)

6. Does the employer that sponsors your Group Health Plan (GHP) employ 100 or more employees? � Yes. (Staff: GROUP HEALTH PLAN IS PRIMARY.) � No. (Staff: MEDICARE IS PRIMARY PAYER UNLESS THE PATIENT ANSWERED YES TO THE

QUESTIONS IN PART I OR II.) PART VI – End-Stage Renal Disease (ESRD)

1. Do you have a Group Health Plan (GHP) coverage based on your own or your spouse’s current/former employment? � Yes. � No.

2. Are you covered under the Group Health Plan (GHP) of a family member other than your spouse?

� Yes. � No. (Staff: MEDICARE IS PRIMARY.)

4

Patient Name:______________________________________

PART VI – End-Stage Renal Disease (ESRD) Continued

3. Does the employer that sponsors the patient’s Group Health Plan (GHP) employ 20 or more employees? � Yes. (Staff: GROUP HEALTH PLAN IS PRIMARY.) � No. (Staff: MEDICARE IS PRIMARY PAYER UNLESS ANSWERED YES TO THE QUESTIONS IN PART I

OR II.)

4. Does the employer that sponsors your Group Health Plan (GHP) employ 100 or more employees? � Yes. (Staff: GROUP HEALTH PLAN IS PRIMARY.) � No. (Staff: MEDICARE IS PRIMARY PAYER UNLESS THE PATIENT ANSWERED YES TO THE

QUESTIONS IN PART I OR II.)

5. Have you ever received a kidney transplant? � Yes. Date of transplant: ____/____/____ MM/DD/YY � No.

6. Have you received maintenance dialysis treatments? � Yes. Date of maintenance: ____/____/____ MM/DD/YY � No.

7. Are you within the 30-month coordination period? � Yes. Date coordination period began: ____/____/____ MM/DD/YY � No. Patient: STOP. DO NOT PROCEED. (Staff: MEDICARE IS PRIMARY.)

8. Are you entitled to Medicare on the basis of either (ESRD and AGE) or (ESRD and DISABILITY)? � Yes. � No. (Staff: GHP IS PRIMARY DURING THE 30-MONTH COORDINATION PERIOD.)

9. Was the initial entitlement to Medicare (including simultaneous entitlement) based on ESRD? � Yes. (Staff: GHP CONTINUES TO PAY PRIMARY DURING THE 30-MONTH COORDINATION PERIOD.) � No. (Staff: INITIAL ENTITLEMENT BASED ON AGE OR DISABILITY.)

10. Does the working aged or disability MSP provision apply (i.e., is the GHP primary based on age or disability entitlement)? � Yes. (Staff: GHP CONTINUES TO PAY PRIMARY DURING THE 30-MONTH COORDINATION PERIOD.) � No. (Staff: MEDICARE CONTINUES TO PAY PRIMARY.)

Effective: 5/7/08

Date & Version # Change Summary 01/18/2014 Ver. 1 Original 04/22/2015 Ver 2 05/21/2015 Ver 3

Updated SNF info Pt. approach created