<p> Karina Garcia, MD Internal Medicine 229 W. Pueblo St. Santa Barbara, CA 93105 www.s a nt a b ar b a ra do c to r .n e t Gene ral In f ormation Pleas e Prin t</p><p>Pe rson al In f ormation</p><p>Name: Date of Birth: / / Address: City: Zip Code: Preferred Phone: Please circle: Mobile H o m e Work Is it okay to leave a private message on the preferred phone: Yes/No Alternative Phone: Please circle: Mobile Home Work Email: Social Security #: / / </p><p>E m p lo y m e n t I n f o r m a t i on Place of Employment: Phone: May we contact you at work? Yes ____No </p><p>E me rgen cy Con ta ct In f or mation</p><p>Name: Address: Zip Code: Phone: Cellular: Relationship to Patient?______</p><p>E -M ail A u t h o r i z a t ion I n f o r m a t ion I hereby authorize the above named physician to send my medical information via E-mail. This authorization will remain in effect until revoked by me in writing. A photocopy of this authorization will be considered as valid and original. Patient Signature: Date: </p><p>I n s u r a n c e I n f o r m a t io n : Please provide receptionist with your insurance card so we can make a copy for our records.</p><p>Ci rc le R e m i nd er Preference : Phone Email Mail Fax</p><p>Circle L an gu age: Dutch English French Spanish Japanese</p><p>Ci rc le R a ce : American Indian Asian African American White Hawaiian or Pacific Islander</p><p>Ci rc le E t hn i c i t y: Hispanic or Latino Not Hispanic or Latino Karina M. Garcia, M.D. 229 W. Pueblo St Santa Barbara, CA 93105 www . s a n t a b a r b a r a d o c t o r . c o m </p><p>Patient Health Questionnaire</p><p>Dr. Garcia would like to get to know you. Please Print.</p><p>Primary reason for today’s visit: </p><p>Medication Allergies: </p><p>Current Medications: Please list ALL medicines including over the counter and supplements</p><p>Name Dose Times taken Daily</p><p>Pharmacy Information</p><p>Name: </p><p>Address: </p><p>Patient Name: D a te: Review of Systems Please mark Yes or No if you have any of the following. Please circle None if this applies to you. YES NO Yes No General Respiratory NONE NONE Weight gain Shortness of breath Weight loss Cough Memory loss Wheezing Fatigue Sputum Fever/chills Night sweats Cardiac Change in appetite NONE Chest pain Eyes Palpitations NONE Murmur Glasses Leg swelling Contact Lenses Blurriness Gastrointestinal Tearing NONE Itching Heartburn Vision Loss Nausea/Vomiting Abdominal Pain Head and Neck Diarrhea NONE Constipation Headache Blood in stool Sore Throat Ear Pain Genitourinary Nasal Discharge NONE Hearing loss Pain with urination Ear Ringing Hesitancy Blood in urine Skin Incontinence NONE Rash Neurologic Eczema NONE Numbness/tingling Musculoskeletal Weakness NONE Joint pain Psychological Joint swelling None Joint stiffness Depressed Anxiety Patient Name ______Date of Birth______Karina Garcia, MD 229 W. Pueblo Street Santa Barbara, CA 93105 www.s a nt a b ar b a ra do c to r .n et Our Financial Policy</p><p>We are dedicated to providing the best possible care for you, and we want you to completely understand our financial policies.</p><p>1. Payment is due at the time of service. We accept MasterCard and Visa.</p><p>2. Keep in mind that your insurance policy is basically a contract between you and your insurance company. As a service to you, we will file your insurance claim.</p><p>3. We have made prior arrangements with Cottage Hospital Insurance to accept an assignment of benefits. We will bill them, and you are required to pay a co-payment at the time of your visit.</p><p>4. If you are insured by a plan that we do not have prior arrangement with, we will prepare and send the claim for you on an unassigned basis. This means the insurer will send the payment directly to you. Therefore, our charges for your care are due at the time of service.</p><p>5. We accept Medicare on an unassigned basis. This means that Medicare will send the payment directly to you. Therefore, our charges for your care are due at the time of service.</p><p>6. Not all insurance plans cover all services. In the event your insurance plan determines a service to be “not covered,” you will be responsible for the complete charge.</p><p>I have read and understand the practice’s financial policy and I agree to be bound by its terms. I Also understand and agree that such terms may be amended by the practice from time to time.</p><p>Signature of patient (or responsible party, if minor) Date</p><p>Please print the name of the patient Please list past medical history including dates: ______</p><p>Please list past surgical history or procedures including dates: ______</p><p>Please list all pertinent family medical history including type of relative (e.g. Aunt) 1. ______6. ______2. ______7.______3. ______8. ______4. ______9. ______5. ______10. ______</p><p>What is your Occupation? ______Relationship status: Married/Partner ____ Single ____ Divorced ____ Widowed ____</p><p>Are you currently sexually active? Yes/No Preferred sexual partner Men ____ Women ____ both ___ never sexually active ____</p><p>Do you smoke? Now/Past/Never If so, how much and for how long: ______</p><p>Do you drink alcohol? Now/Past/Never If so, how much: ______</p><p>Vaccines: If received, please give date: Tetanus/tdap______Influenza ______Hepatitis A / B ______Pneumonia ______Shingles ______Gardasil ______</p><p>Women’s Health Last Menstrual Cycle: ______Are you on birth control /type? ______</p><p>Number of Pregnancies: ______Number of births: ______Pap Test:______Breast Exam/Mammogram: ______</p><p>Please describe your diet and physical activity/exercise: ______Preventative, please include dates:</p><p>Colonoscopy: ______Bone Density Test: ______</p><p>Most recent set of lab work:______</p><p>Patient Name:______Date of Birth:______</p>