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Maria Milian Sobarzo M.D., P.A. 21402 Provincial Blvd Katy TX 77450 281.398.0777 Patient Name: Last ______________________ First ____________________ Middle ___________ Address: __________________________________________ City, State, Zip __________________ Tel: Home ___________________ Work ____________________ Cell _______________________ Check one: Employed ____ F/T Student ____ P/T Student ____ Unemployed _____ Check one: Single ____ Married ____ Other ____ Drivers Lic # ___________________________ Patient Spouse/Parent Employer/School ____________________________ Name _________________________________ Address ____________________________________ Work Number __________________________ SS# _______________________________________ SS# ___________________________________ Date of Birth ________________________________ Date of Birth ___________________________ Referred by: Physician _____ Friend _________ Name: ________________________________________________ Self ________ Next of Kin: _______________________________ Tel: __________________________________ Relative of Friend not living at same address: Name: __________________________________ Relationship ______________________________ Address ___________________________________________ Tel ____________________________ Primary Insurance Ins Co ___________________________________ Secondary Insurance ______________________________________ Claims Address ___________________________ ______________________________________ City, St, Zip ______________________________ ______________________________________ Group Number ____________________________ ______________________________________ Policy/Id # _______________________________ ______________________________________ Assignment of Insurance Benefits and Authorization to release Information: I authorize payment of medical benefits to Maria Milian Sobarzo MD for any and all services rendered. I authorize Maria Milian Sobarzo MD to release any medical information necessary for the processing of my medical insurance claims. Patient _________________________________________ Date ______________________________ Responsible Party Signature _____________________________ Relationship ___________________ Date ______ Date _________________ Name __________________________________ Age ________ Genetic: If you or your husband are in the following categories, please respond Yes or No African American or Indian descent, have you or your husband had Sickle Cell carrier testing? ____ Italian or Greek descent, have you or your husband had Thalassemia carrier testing? _______ Jewish descent, have you or your husband had Tay-Sachs carrier testing? _______ Additional explanation of past history __________________________________________________ _________________________________________________________________________________ Race _____________________________ Occupation _____________________________________ Do you drink Alcohol? ______ If yes, estimated number of drinks per week ____________________ Do you smoke? ______ How many packs per day? ________________ Are you using any other drugs? ___________ Type? _______________________________________ Are you sexually active? _____ Any difficulties or discomfort? ______________________________ Family History: Is there a member of your family with a history of: _____ Cancer – Type: __________ Who? ____________________________ _____ Congenital (Inherited) Disease Who? ____________________________ _____ Diabetes Who? ____________________________ _____ Heart Disease Who? ____________________________ _____ High Blood Pressure Who? ____________________________ _____ High Cholesterol Who? ____________________________ _____ Kidney Disease Who? ____________________________ _____ Mental Retardation Who? ____________________________ _____ Osteoporosis Who? ____________________________ _____ Twins Who? ____________________________ Date of Last Pap Smear _________________ Results ____________________________ Date of Last Mammogram ______________ Results ____________________________ Date of Last Bone Density ______________ Results ____________________________ Reason for today’s visit ____________________________________________________ ________________________________________________________________________ What changes have there been in your life recently? ______________________________ Pharmacy Name and Phone # ________________________________________________ Do you need 30 or 90 day prescriptions? _______________________________________ Date _________________ Name ________________________________ Age _________ Past History: Circle all that apply Arthritis Asthma Breast Tumor Diabetes Heart Attack Hepatitis High Blood Pressure High Cholesterol Intestinal Bleeding Heart Murmur Migraine Headaches Mitral Valve Prolapse Neurological Disease Osteoporosis Kidney Infection Rheumatic Fever Thrombophlebitis Thyroid Problems Pneumonia Kidney Stone Other Heart Disease ________________ Infectious Disease (TB, HIV, etc) ______________ Other Kidney Disease _______________ Other Lung Disease _________________________ Other __________________________________________________________________________ List all Surgeries Type of Surgery Date 1. _______________________________ Type of Surgery Date 3. _______________________________________ 2. _______________________________ 4. _______________________________________ Number of: Pregnancies ____ Deliveries ____ Miscarriages ____ Abortions ____ Living Children _____ Please list pregnancies in chronological order: Date Sex Wt Type of Delivery Complications _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Will you permit a Blood Transfusion for medical reasons? __________ Date of last menstrual period ______________ Are your periods regular? ______________ Any problems with periods? ____________________ Present type of Birth Control ____________ Do you want to change birth control? ___________ To what? ______________________________ Did your mother take DES or other hormones while pregnant with you? ______________________ Female Organs: Circle any that you have had Abnormal Bleeding Herpes Infection Tubal (Ectopic) Pregnancy Chlamydia/Gonorrhea/Syphilis Infection of Tubes or Ovaries Tumor of Uterus or Ovaries Genital Warts Abnormal Pap Smear ________Treatment __________________________________________________ List all currently used medications ________________________________________________________ _____________________________________________________________________________________ List all allergies to medications ___________________________________________________________