State: Zip:

Employer:

Signature:_________________________________________________________Date:__________________________

Dr. Mark Tafazoli

Name: Date of Birth:

Street: Suite/Apt:

General Patient Information

Phone: (256) 775-1090 / Fax: (256)736-6228

1800 Alabama Hwy 157, POB 3, Suite 303 Cullman, AL 35058

CO-PAYS AND DEDUCTIBLES ARE TO BE PAID AT THE TIME OF SERVICE.

SSN:City:

Primary care physician: Telephone: Patient's (or Guardian's)

Emergency contact: Telephone: Relationship:

Date of Birth: Relationship:

Policy number: Group number:

8489 Madison Boulevard Madison, AL 35758

Primary Insurance Company:

PLEASE PRESENT INSURANCE CARD(S) AND PHOTO I.D. OR VALID DRIVER'S LICENSE TO BE COPIED FOR PATIENT CHART

Health Insurance Information

Phone(home): Phone(other): []Work []Cell

E-mail address:

Primary pharmacy: Telephone:

Insured name:

If health professional, please provide name, location, and telephone number:

Source of referral to this office is: [] A physician or other medical professional []A mental health professional

[] A friend or family member [] Internet []Telephone book [] Insurance company [] Other________________

I authorize Cullman Primary Care, P.C. to release any information requested by my insurance company, including diagnosis

and records of any treatment for medical or surgical services. I also authorize and request that my insurance company pay

directly to Cullman Primary Care, P.C. the amount due in my pending claim for services rendered to me. I understand I am

also responsible for any amount that my insurance does not pay. I also understand that I am responsible for any fees or

charges accrued in the process of collecting past due amounts on my account, including reasonable attorney's fees in the

event my medical/surgical bills are placed with an attorney or other third party.

Secondary Insurance Company:

Policy number: Group number:

Insured name: Date of Birth: Relationship:

Sleep

Dia

ry

Mark

Tafazoli

M.D

.E

xam

pleof

sleepdiary

asshow

nbellow

:e.g.sleep

time

10:30pm-7am

and10:30pm

–7am

with

waking

up3:30

-4:30am

Date

12p

m1

pm

2p

m3

pm

4p

m5

pm

6p

m7

pm

8p

m9

pm

10p

m1

1pm

12am

1am

2am

3am

4am

5am

6am

7am

8am

9am

10am

11am

9/27/08

9/28/08

No

wp

leasesh

ow

usyo

ur

sleepp

attern;w

hen

you

goto

bed

,and

wak

eu

pand

out

of

bed

Date

12p

m1

pm

2p

m3

pm

4p

m5

pm

6p

m7

pm

8p

m9

pm

10p

m1

1pm

12am

1am

2am

3am

4am

5am

6am

7am

8am

9am

10am

11am

Pediatric Sleep History and Symptom FormMark Tafazoli M.D., DABFP, CAQSM 1800 Alabama Hwy 157 POB 3, Suite 303, Cullman, AL 35058 / 8489 Madison Boulevard Madison, AL 35758 Phone: (256) 775-1090/ Fax: (256) 736-6228

Name______________________________ Age____ Female Male DOB_____/_____/_____Today’s Date _____/_____/_____

What brings your child to our office today?__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Child’s Main Complaints: Parent’s main complaint (about child’s sleep)Daytime sleepiness Daytime sleepinessInsomnia InsomniaSnoring SnoringInterruptions in breathing Interruptions in breathingLeg jerks Leg jerksOther_______________ Other__________________

Sleep history:How long has your child’s complaints bothered him/her?Last 3 months 6-12 months 1-2 years >2 years

How would you rate the severity of your child’s complaints:Mild Moderate Severe

Has the child had a previous sleep study? Yes….. No….When____________ Where_____________ Physician______________What was recommended?_________________________

Sleep Schedule(1) During the week …..What time does your child normally go to bed ____________ a.m. / p.m. Total sleep time in 24hrs______

What time does your child normally awaken ____________a.m. / p.m.(2) During the weekend..What time does your child normally go to bed ____________ a.m. / p.m.

What time does your child normally awaken ____________ a.m. / p.m.(3) How long does it take your child to get to sleep? _______________ min / hours(4) Approximately how many times does the child awaken during their sleep cycle? ________ How long to get back to sleep? ________(5) What are the usual reasons that awaken the child?

Urination HeatShortness of breath ColdHeartburn lightBody Jerks Painnoise Siblingother___________________ Check if applicable

(6) Does your child sleep through the night? ........................................................................yes no (7) Does your child sleep with parents bed/bedroom?...........................................................yes no (8) Does anyone leave the bedroom b/c of your child’s sleep problem? ………..................yes no(9) Does the child awaken feeling tired and not refreshed?...................................................yes no (10) Take naps on arrival home from work/school? …………………………………....….yes no (11) Are short naps refreshing?..............................................................................................yes no (12) Does your child fall asleep while driving or riding in a car? ….…………………….. yes no (13) Have trouble at work or school b/c of sleepiness?........................................................ yes no (14) Snore loud enough for others to complain? …………………………………….……. yes no (15) Stop breathing?............................................................................................................. yes no (16) Awakened short of breath or choking? ……………………………………...……….. yes no (17) Awakened with heart burn belching or coughing?........................................................ yes no (18) Awakened with chest pain or chest heaviness? ……………………………………….yes no (19) Awakened with heart racing or pounding?......................................................................yes no (20) Wake up with morning headache? ………………………..……………………………yes no (21) Have poor memory?.........................................................................................................yes no (22) Trouble concentrating? ………………………………………….……………………. yes no

(23) Has your child’s family relationship been affected b/c of they are tired or sleepy?..... yes no(24) Does your child feel the uncontrollable urge to sleep while sad, happy or mad? .........yes no Narcolepsy screening

(25) Feel their knees buckle arms weak, or jaw drop when mad happy or sad?....................yes no(26) Experience vivid dream-like scenes upon awakening or falling sleep? ………………yes no(27) Feel unable to move (paralyzed) when waking from or falling asleep?.........................yes no(28) Have leg cramps at bedtime? ………………………..…………………..……………yes no PLM screening

(29) Experience crawling and aching feeling in arms or legs which makeshim/her want to move them?......................................................................................yes no

(30) Leg move throughout the night? …………………………………………..………….yes no(31) Awaken suddenly with a jerk soon after falling asleep?................................................yes no(32) Remember his/her dreams? ……………………………………………………….…..yes no Parasomnia Screening

(33) Have nightmares?...........................................................................................................yes no(34) Act out his/her dreams (talk or move)? ……………………..…….…………………..yes no(35) Sleepwalk?.....................................................................................................................yes no(36) Awaken from sleep confused / inconsolable? ……………………………………….. yes no(37) Awakened panicked or anxious?....................................................................................yes no(38) Unable to fall asleep in 15 minutes or less? …………………………..………………yes no Insomnia screening

(39) Wake up several times during the night and cannot get back to sleep?..........................yes no(40) Wake up 1 or 2 hours early in the morning? ………………………………………….yes no(41) Have thoughts racing through his/her mind while trying to sleep?................................yes no(42) Watch the clock while trying to fall asleep? ………………………………….……… yes no(43) Wake up stiff in the morning?........................................................................................ yes no Depression/fibromyalgia

(44) Wake up with sore achy muscles? ................................................................................. yes no screening

(45) Feel depressed or sad?.................................................................................................... yes no(46) Clench their teeth? …………………………………………………………………….. yes no Bruxism screening

(47) Grind teeth during sleep?................................................................................................ yes no(48) Have morning jaw pain? ……………………………………………………………… yes no

Epworth Sleepiness Scale Please check all that applies to your child.How likely is your child to doze off to sleep in the following situations?

(0) (1) (2) (3)would never Slight chance Moderate chance high chancedoze of dozing of dozing of dozing

Situation1- Sitting Reading 2- Watching TV_____________________________________________ 3- Sitting, inactive in a public place (i.e. theater or meeting) 4- As a passenger in a car for an hour without break_________________ 5- Lying down to rest in the afternoon when circumstances permit 6- Sitting down talking with someone____________________________ 7- Sitting quietly after lunch without alcohol 8- In a car, while stopped for a few minutes in traffic________________

Epworth Total____/ 24

Birth history: Please answer to the best of your recollection regarding child:

Did the child’s mother receive regular prenatal care while pregnant? Yes… No…Were there any complications during pregnancy with this child? Yes… No… If yes, explain ________________________________Were there any complications post delivery with this child? Yes… No… If yes, explain ____________________________________Birth Weight __________ #wks of gestation ________ Length of labor _________ APGAR score _______@ 5 minsType of delivery? SVD (vaginal)….. C-section Any birth defects / trauma ….Yes…No… If yes, explain __________________Jaundice…Yes…No Prolonged neonatal stay? ….Yes….No… If yes, explain _______________________________________Other__________________________________________________________________________________________________________

Social History: Please check all that applies to your child:

Number of siblings _____ Does child have own room? Yes…No Does the child sleep in their own bed? Yes…NoAre there pets in house Yes…No _________ If yes, do the pets sleep with the child Yes…No Is there any smoking in house (2nd hand tobacco smoke) Current… Past Home family status: Married Separated Divorced Joint Custody Civil Union Foster careDoes your child have special needs? __________________________________________________________

To the best of your knowledge, does your child use the following: Please check (if applicable):Alcohol use Current past Type/how much?_____________________Illicit drug use Current past What drug? _________________________Nicotine abuse Current past Type/Packs per day?___________________Caffeine Current past How many cups/glasses/cans per day?_______________

Past Medical History: Please check any of the following conditions that apply to your child or your family:Child Father Mother Sibling Grandma Grandpa

Alcoholism…………………. ________________________________Arthritis pain……….………. ________________________________Asthma…………….……..… ________________________________Cancer……………………… ________________________________Congestive Heart Failure...… ________________________________Depression……………….… ________________________________Diabetes………………….… ________________________________Emphysema / COPD……..… ________________________________Fibromyalgia……………..… ________________________________Acid reflux………….…...…. ________________________________Heart attack………………... ________________________________Heart Arrhythmia………...… ________________________________High Blood Pressure……..… ________________________________High Cholesterol …….……. ________________________________Narcolepsy ………………… ________________________________Migraine Headache………… ________________________________Psychiatric problem……...… ________________________________Restless Legs……….……… ________________________________Seizures / Epilepsy……….…. ________________________________Stroke………………….…… ________________________________Sleep Apnea………………… ________________________________Tuberculosis……………...… ________________________________Thyroid disease…………..… ________________________________Other…………………..…… ________________________________

Past Surgeries: What surgeries has your child had in the past?Abdominal surgery……. ____________________ ___/___/___ Brain/ Head…… ______________________ ___/___/___Appendectomy………. ____________________ ___/___/___ Heart surgery….. ______________________ ___/___/___Hernia………..……….. ____________________ ___/___/___ Gallbladder…..... ______________________ ___/___/___Ear Tubes ….…………. ____________________ ___/___/___ Tonsillectomy…. ______________________ ___/___/___Circumcision…………. ____________________ ___/___/_____ Other………….. ______________________ ___/___/___

Current medication: Please indicate any vitamins, herbs, and over the counter medications that your child currently takes.1._____________________ 4._______________________ 7._______________________ 10.___________________2._____________________ 5._______________________ 8._______________________ 11.___________________3._____________________ 6._______________________ 9._______________________ 12.___________________

Allergies: List any medication, food, or chemicals which your child is allergic to or has a major side effect to:1._____________________ 3_______________________ 5._______________________ 7.___________________2._____________________ 4._______________________ 6._______________________ 8.___________________

Review of Symptoms: Check any symptom that applies to your child at this time.

Sleep Eyes / ENT Musculoskeletal Pulmonary Daytime sleepiness Sinus trouble Muscle pain Chronic cough Dry mouth Difficulty hearing Joint pain Coughing blood Snore Difficulty seeing Back pain Shortness of breath Sore throat Sneezing / watery eyes Leg jerks Sputum production Apnea Nose bleed Leg pain with walking Wheezing Daytime naps Use of Oxygen Insomnia Cardiovascular Gastrointestinal

Chest pain Nausea / vomiting NeurologicalGeneral Shortness of breath Heart burn Memory Loss Night sweats Rapid/skipped heartbeats Irritable bowel Dizziness Weight gain Ankle swelling Difficulty swallowing Difficulty walking Fatigue Difficulty talking Weight loss Urinary Psychological Tremors Hot flashes Frequent urination Depression Numbness/tingling

Nighttime urination Anxiety One-sided weakness Urinary incontinence Hallucinations Morning headache

Do you wish your child to be on life support?………………….Yes….No _______________________________________________Do you have some one else to make health decisions for you regarding your child in case you were incapacitated Yes…..No….. Ifyes, please list the names of persons who can also make health decisions for your child. _____________________________________________________________________________________________________________________________________________________

Do you wish to add anything else regarding your child’s sleep issues?______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I certify that the above information is accurate to best of my knowledge. I understand withholding information be it intentional, or bynegligence to fill out this form, could result in improper medical care and could be a detriment to my health or even life threatening.

__________________________________Patient/Guardian Signature

For Physician Use Only (Do Not Write Below This Point)

Wt BP Neck Circ. Pulse Pulse ox BMI

Allergies:

CC:

ROS:

Education provided

Cullman Primary CareDr. Mark Tafazoli

1800 Alabama Hwy 157, POB 3, Suite 303 Cullman, AL 35058/ 8489 Madison Boulevard Madison, AL 35758

Phone: (256) 775-1090

Fax: (256) 736-6228

Patient Name: __________________________________ DOB _____/_____/______

Address: _____________________________________City:__________________State:_____ Zip Code:_______

Social Security #_____________________________ (for ID purposes only)

Doctor/Hospital Name: (OFFICE USE ONLY): _____________________________________________

To disclose the following specific medical information for the purpose of DOCTOR REVIEW:

My authorization extends only to elements / documents below:

____ HISTORY AND PHYSICAL

____ PROGRESS NOTES

____CONSULTATION REPORT

____DISCHARGE SUMMARY

____PHOTO, VIDEO, DIGITAL, OR OTHER IMAGES

____MENTAL / ALCOHOL / DRUG ABUSE TREATMENT

____ AIDS, HIV, AND/OR HEPATITIS INFORMATION.

____LABS

____OTHER ____________________________________________________

This authorization is given freely with the understanding that:

1. Any and all records, whether oral or in electronic format, are confidential and cannot be disclosed

without my prior written authorization, except as otherwise provided by law.

2. A photocopy or fax or this authorization is as valid as this original.

3. I may revoke this authorization at any time, except where information has already been released.

This authorization is valid for a one (1) year period from the date it is signed or sooner if noted

below. The revocation must be in writing, and a revocation form is available from the receptionist.

4. Cullman Primary Care, PC., its employees, officers, and physicians are hereby released from any

legal responsibility or liability for disclosure of the above information to the extent and authorization

herein.

____________________________________________ ______________________

Patient/Guardian signature (if a minor) Date

WE ARE NOW CHARGING A $25 CHARGE FOR ANY NO SHOW APPOINTMENTS

IF YOU ARE UNABLE TO KEEP YOUR SCHEDULED APPOINTMENT PLEASE CALL US AT

LEAST 24 HOURS PRIOR TO YOUR APPOINTMENT SO THAT WE CAN RESCHEDULE AND/

OR CANCEL YOUR EXISTING SPOT SO THAT OTHER PATIENTS CAN BE SCHEDULED.

IT IS OUR COMPANY POLICY THAT AFTER 3 MISSED APPOINTMENTS, WE WILL NO

LONGER BE ABLE TO SEE YOU. WE ATTEMPT TO REACH ALL OF OUR PATIENTS BY

TELEPHONE TO CONFIRM THEIR APPOINTMENTS. PLEASE CALL THE OFFICE AND

UPDATE ANY PHONE NUMBERS.

SIGNATURE:______________________________DATE:___________________

Cullman Primary Care Patient Consent Form

I understand that as part of the provision of healthcare services, CULLMAN PRIMARY CARE, P.C. creates and maintains health records and other information describing among others things, my health history, symptoms, examinations and test results, diagnoses, treatment and any plans for future care and treatment. I have been provided with a Notice of Privacy Practices that provides a more complete description of the uses and disclosures of certain health information. I understand that I have the right to review the notice prior to signing the consent. I understand that the organization reserved the right to change their notice practices and prior to implementation will mail a copy of any revised notice to the address I have provided. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment and health care operations (quality assessment and improvement activities, underwriting, premium rating, conducting or arranging for medical review, legal services, and auditing functions, etc.) and that the organization is not required to agree to the restrictions requested. By signing this form, I consent to the use and disclosure of protected health information about me to the purposes of treatment, payment and healthcare operations. I have the right to revoke this consent in writing, except where disclosures have already been made in reliance on my prior consent. This consent is given freely with the understanding that:

1. Any and all records, whether written or oral or in electronic format are confidential and cannot

be disclosed without my prior written authorization, except as otherwise provided by law.

2. A photocopy of fax of this consent is valid as this original.

3. I may revoke this consent at any time, except where information has already been released. This

consent is valid until revoked by me in writing.

4. I have the right to request that the use of my Protected Health Information which is used or

disclosed for the purpose of treatment, payment or healthcare operations be restricted. Cullman

Primary care, P.C. is not bound by the restriction unless it is in agreement with the restriction.

Patient’s Name (Printed):___________________________________ Date: ________________________ Patient’s Signature(or Guardian if minor):___________________________________________________ SSN#_______________________________ Witness:____________________________________ Date:____________________________

Cullman Primary Care P.C. Multi-Specialty Group 503 Clark Street N.E. Cullman, AL 35055

PLEASE READ THIS PAGE CAREFULLY AND THEN SIGN By signing this form, I hereby give permission for all medical treatment by or under the supervision of the physicians located at this practice. I consent to the release of medical information to my insurance company if necessary for the processing of my claims. I agree to pay the physician fees in the usual and customary manner, and I understand the FEES FOR AN OFFICE VISIT MUST BE PAID AT THE TIME OF SERVICE, unless an agreement has been made with the collections department prior to the visit. I also understand that I, and not my insurance company, am responsible for any physician fees. I further agree to pay court costs, collection costs, and any attorney fees for the fees which could not be collected in the usual and customary manner.

COMMUNICATIONS REGARDING MY ACCOUNTS: Until my accounts are finally settled, I give my direct consent to receive communications regarding my accounts from any servicers and any collectors of my accounts, through various means such as 1) any cell, landline or text number that I provide, 2) any email address that I provide, 3) auto dialer systems, 4) voicemail message and/or any other forms of communications that I provide. I also agree to reimburse Cullman Primary Care the fees of any collection agency, which may be based on the percentage at a maximum of 33% of the debit, and all cost and expenses, including reasonable attorney fees, we incur in the collection effort.

NON-COVERED ROUTINE SERVICE POLICY: We want to provide you the best care possible. There may be certain services that we feel are necessary for the maintenance of good health that may not be covered by your insurance policy (for example: vaccines or radiology test). You will be responsible for paying for these services in full. If you have any questions regarding coverage or if a particular service is covered please call your insurance company to insure coverage of the service.

TERMINATION OF TREATMENT: By signing this form, I hereby understand and agree that the physicians in this practice may terminate the physician-patient relationship. We base our relationship on mutual trust and respect, and any event of action by the patient which disturbs this trust, including significant failure to comply with our information, or other actions not mentioned here will, result in a written termination of our relationship. Upon receipt of written notice you will have 30 days to transfer your care to another physician. Termination notification will be mailed to the patient’s current address and shall be considered received by the patient upon the date mailed. POLICY CONCERNING DIVORCE SETTLEMENT: The policy of Cullman Primary Care is that responsible party for a child of divorced parents must arrange for payment to be made at the time of the child’s office visit. Regardless of the terms of your divorce settlement, whoever brings the child in must pay for the office visit at the time of service. Signature of Responsible party: _______________________________ Date:__________________ Address:___________________________________________________ Phone#:________________

Cullman Primary Care, P.C. Multi- Specialty Group 503 Clark Street N.E. Cullman, AL 35055

Privacy Compliance

Please list the family members or other persons, if any we may inform about your general medical condition and your diagnosis, which might include medical history, treatment, laboratory reports, x-rays, treatments, reference to any mental or nervous disorders, drug and/or alcohol abuse or sexually transmitted disease. ___________________________ Relationship____________________ Phone_______________ ____________________________ Relationship____________________ Phone_______________ ____________________________ Relationship____________________ Phone_______________ ____________________________ Relationship____________________ Phone_______________ ____________________________ Relationship____________________ Phone_______________ Please list the family members or other persons, if any, we may inform about your general medical condition and your diagnosis ONLY IN AN EMERGENCY SITUATION. ____________________________ Relationship___________________ Phone_______________ ____________________________ Relationship___________________ Phone_______________ ____________________________ Relationship___________________ Phone_______________ Please print the telephone number, if any, where you want to receive calls about your appointments, test results, and/or any other health information, if other than your home phone. ____________________________________________ Can confidential messages be left on your home answering machine or voicemail? ______________Yes _______________ No Would you like to have access to the Patient Portal? (The portal is where you can log in and request appointments, refills and review you last labs) _____________________ Yes _________________ No If yes, Please provide your email address and you should receive an invite to join the Patient Portal within a few business days. Email Address:__________________________________________________________ Patient Signature & Date of Birth:_________________________________ Date:___________________

Cullman Primary Care P.C. Multi-Specialty Group 503 Clark Street N.E. Cullman, AL 35055

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can

get access to this information. Please review it carefully.

Protecting your Privacy:

Protecting your privacy and your medical information is at the core of our business. We recognize out obligation to keep your

information secure and confidential whether on paper or the internet. At Cullman Primary Care, P.C., privacy is one of our

highest priorities.

Keeping your information:

Keeping the medical and health information we have about you secure is one of our most important responsibilities. We

value your trust and will handle your information with care. Our employees access information about you only when

necessary to provide treatment, verify eligibility, obtain authorization, process claims and otherwise meet your needs. We

may also access information about you when considering a request from you or when exercising out rights under the law or

any agreement with you.

We safeguard information all business practices according to established security standards and procedures, and we

continually assess new technology for protecting information. Our employees are trained to understand and comply with the

information principles.

Working to meet your needs through information:

In the course of doing business, we collect and use various types of information, like name and address and claims

information. We use this information to provide service to you, to process your claims and to bring you health information

that might be of interest to you.

Keeping information accurate:

Keeping your health information accurate and up-to-date is very important. If you believe the health information we have

about you is incomplete, inaccurate or not current, please call or write us at the telephone number listed below. We take

appropriate action to correct any erroneous information as quickly as possible through a standard set of practices and

procedures.

How and why information is shared:

We limit who receives information and what type of information is shared.

• Sharing information within Cullman Primary Care, P.C.--- We share information within our company to

deliver you the health care services and the related information and education programs specified in your

plan.

• Sharing information with companies that work for us—To help us offer you our services, we may share

information with companies that work for us, such as claim processing and mailing companies and

companies that deliver health education and information directly to you. These companies act on our behalf

and are obligated contractually to keep the information that we provide them confidential.

• Other---Patient specific personally identifiable data is released only when required to provide a service for

you and only to those with a need to know, or with your consent. Data is released with the condition that the

person receiving the data will not release it further, unless you give permission.

If we receive a subpoena or similar legal process demanding release of any information about you, we will attempt to notify

you (unless we are prohibited from doing so). Except as required by law or as described above, we do not share information

with other parties, including government agencies.

Cullman Primary Care, P.C. does not share any customer information with third-party marketers who offer their products and

services to our patients.

Count on our commitment to your privacy:

You can count on us to keep you informed about how we protect your privacy and limit the sharing of information you

provide to us whether it’s at our office, over the phone or through the internet.