621 N. Hall Street Dallas, Texas 75226 (214) 820-0600 www.BaylorHealth.com

Thank you for choosing Baylor Jack and Jane Hamilton Heart and Vascular Hospital for your health care needs. Enclosed you will find forms that require completion prior to your arrival. This information will allow us to begin preparing for you and your procedure. Please read each question thoroughly and print your answers clearly using a black ink pen. If you make an error, draw a single line through the error and write the correct answer. If you do not understand a question or you are unsure how to answer it, leave the question blank and ask your nurse for assistance on your We ask that you bring all medications you are currently taking in their original pharmacy containers. The timing of your procedure may vary depending upon the needs of the patients scheduled before you. On occasion, emergency cases arise and must be handled as priority by our staff. Should this occur, your procedure time may be delayed. You may wish to bring a book, crossword puzzles or a magazine to enjoy. If you have any questions regarding scheduling of your procedure, please feel free to call our scheduling department at 214-820-0128, Monday through Friday from 9 AM to 5:30 PM. If you have questions about insurance benefits, copays or what your estimated patient portion will be, please do not hesitate to contact our Access Services Team at 214-820-0673. Our team will be happy to help you determine what the expected payment will be based on your individual insurance coverage. Our hours of operation are 8:00 AM to 5:00 PM CST Monday through Friday. Again, thank you for choosing Baylor Jack and Jane Hamilton Heart and Vascular Hospital. If I can be of any assistance, I may be reached at 214-820-0660. Sincerely,

Nancy Vish, RN, PhD, NEA-BC, FACHE President and Chief Nursing Officer Baylor Jack and Jane Hamilton Heart and Vascular Hospital

BAYLOR JACK AND JANE HAMILTONHEART AND VASCULAR HOSPITAL

DALLAS, TEXAS

PATIENT DATABASEPage 1 of 3

BHVH-53938 (Rev. 12/12)

Patient Name: Date of Birth:

Primary Care Physician: Phone Number:

Do you have any of the following allergies? If yes please list reaction to allergen.

Food Allergy: No Yes: List food allergy with reaction:

Drug Allergy: No Yes: List drug allergy with reaction:

Latex Allergy: No Yes: List reaction:

Have you ever had any of the following (Please check ALL that apply): None Abdominal Aortic Aneurysm Alzheimer’s Heart Attack Amputation: Location Anemia Angina/Chest pain Arthritis: Location Asthma Back Pain: Upper/Middle/Lower Bleeding Disorder

Type: Blood disorder

Type: Cancer: Location

Treatment Cataract Cerebral Palsy Chronic Fatigue Syndrome Irritable Bowel Syndrome Meniere's Neuropathy Pancreatitis Pneumonia Rheumatoid Arthritis Thyroid: Low/High Ulcerative Colitis

COPD Cochlear Implants Colitis Congestive Heart Failure Constipation Coronary Artery Disease Crohn’s Disease CVA (Stroke/TIA) Deep Vein Thrombosis (DVT) Dementia Diabetes Insulin Dependent Diabetes Non-Insulin Dependent Dialysis: Hemo/Peritoneal: MWF/TTHS Diverticulitis End Stage Renal Disease Kidney stones Meningitis Nose Bleeds Parkinson’s Psychiatric:

Explain: Sickle Cell Traumatic Brain Injury Urinary Tract Infection

Fainting Fibromyalgia Gallstones GERD Gastrointestinal Bleeding Glaucoma Head Injury Hemorrhoids Hepatitis A/Hepatitis B/Hepatitis C Hernia High Cholesterol High Risk Pregnancy HIV/AIDS High Blood Pressure Irregular Heart Rate:

Explain: Liver Disease Migraine Palpitations Peptic Ulcer Pulmonary Embolism Sleep Apnea: CPAP/BIPAP Ulcer

BAYLOR JACK AND JANE HAMILTONHEART AND VASCULAR HOSPITAL

DALLAS, TEXAS

PATIENT DATABASEPage 2 of 3

BHVH-53938 (Rev. 12/12)

For Women Only:

Are you: N/A Pregnant Menstruating Menopausal Unknown

Date of last menstrual period: _____ /_____ /_____ Have you had a hysterectomy (circle)? No / Yes

Have you had a mastectomy (circle)? No / Yes If yes specify what side (circle): Right / Left

Are you breast-feeding or lactating? No / Yes

Number of times you have been pregnant: _____ Number of children: _____ Abortion: _____

Please list ALL Surgeries with Dates: Never Had Surgery

Do you have any implants (please circle all that apply): N/A

Aneurysm Stent or Aneurysm Clip Coronary Stents Middle Ear Prosthesis Joint Replacement

(specify): Pacemaker/ICD

Specify: Body Art

Artificial Heart Valve Renal or Other Stents Implanted Devices/Pumps/Stimulator Lens Implants Penile Implant Body Piercing

Artificial Limbs Prosthetic Eye Metal Implants Pins/Rods/Screws (specify):

Tracheotomy Other (please specify):

Have you had a previous adverse reaction to anesthesia? No Yes

If YES, please specify:

Vaccines:

Please list dates of last dose on the following vaccines: Unknown

Tetanus Hepatitis B Rotavirus Haemophilus Influenzae Type b (Hib)

Polio Vaccine MMR Flu Flu, H1N1

Hepatitis A Varicella Meningococcal Pertussis (whooping cough)

HPV RSV

BAYLOR JACK AND JANE HAMILTONHEART AND VASCULAR HOSPITAL

DALLAS, TEXAS

PATIENT DATABASEPage 3 of 3

BHVH-53938 (Rev. 12/12)

Living Environment Screening:Do you live: Alone Children Friend Grandparents Parents Spouse Other (specify): Do you care for someone in the home (specify)? No Yes

If yes whom: Children Friend Parent Pet Significant other Spouse Other (specify) Anticipated changes because of illness: None Inability to care for self

Inability to care for someone else Inability to work Other (specify) Who will be helping you with your care when you leave?

Name Relationship __________________ Phone # Describe your living conditions:

Apartment Assisted Living Extended Care Facility Foster Care House Homeless No Permanent Address Other (specify)

Do you have resources to obtain your medication? Yes NoDo you use any community agencies? No Yes If yes please specify Sleep Apnea Screening:Have you ever been diagnosed with obstructive sleep apnea? No Yes

If Yes what is your current treatment: Bi-Pap C-Pap Other (specify) Have you had surgery for sleep apnea? No YesDo you snore most nights? No Yes Is your snoring loud? No YesHave you ever been told that you stop breathing or gasp during your sleep? No YesDo you occasionally doze or fall asleep during the day when you are not busy or active? No YesSubstance Use: Never used Tobacco Current Tobacco Past Use Caffeine Current Use Alcohol Current Alcohol Past Street drug/Inhalant/Medication Abuse Current Street drug/Inhalant/Medication Abuse Past If Street Drug/Inhalant/Medication Abuse Please Check All That Apply:

amphetamines depressants ecstasy hallucinogens heroin inhalants (solvents, gasses, nitrites, aerosols) marijuana mescaline methamphetamine narcotics PCP (phencyclidine) sedatives steroids stimulants

Duration of Street Drug/Inhalant/Medication Use (month/Years): ______ Last time used : Do you have exposure to second hand smoke: No YesSuicide Risk screening:Are you feeling hopeless or worthless? No YesAre you having thoughts of taking your own life? No Yes Unknown Describe: For Hemodialysis patient ONLYHemodialysis days: MWF or TThS (please circle)Type of access: Right or Left (please encircle)

Hemodialysis Center: Hemodialysis Phone Number:

Nephrologist:

Rev. 5/7/15

PATIENT HOME MEDICATION LIST Please complete this form prior to your procedure.

Include all current medications you are taking - including prescriptions, herbal supplements,

over-the-counters, vitamins, patches, blood thinners, ointments, eye drops, aspirin etc.

My Current Pharmacy Information:

Pharmacy Name: __________________________________________________________________

Pharmacy Address: ________________________________________________________________

Pharmacy Telephone #: ( ) - ________ - __________

MEDICATION NAME Example: Aspirin, Coumadin, St. John’s Wort, Vitamin C

STRENGTH & DOSE Example: 10 mg, 2 tablets

FREQUENCY Example: Once a day, as needed

LAST DOSE TAKEN Example: 5/13 at 8am

A GUIDE TO YOUR CARE

1

BHVH-1101 (Rev. 11/14)

Important information about medical and ethical issues If you are reading this guide, you are probably in the hospital or preparing to be in the hospital. Our goal while you are a patient in our hospital is to help you experience the best possible outcome. For this to happen, everyone—you, your family and your health care team—must all work together and communicate clearly. This guide is provided to help you understand how you and your family can work with your health care team toward the goal of achieving the best possible outcome, as well as to help you understand what your rights and responsibilities. We know that a hospital can be a confusing place. You may have many different doctors who visit when your family isn’t nearby. Physicians and nurses may use words you don’t understand. You may have questions about hospital rules or your rights as a patient. You may be very sick and hard choices may need to be made about your treatment. Making those decisions can be difficult and emotions may be strong. We hope the information you find in this guide will ease your mind, make you feel comfortable communicating with your health care team about your treatment or any other issues, and enhance the experience of both you and your family.

Your rights and responsibilities as a patient As a patient, you have certain rights and responsibilities. As a hospital, it is our responsibility under federal law and hospital accreditation standards to inform you of those rights and responsibilities. For example, you have the right to:

• information about your condition, treatment options and test results • information about outcomes that may be different from what you and your family

expected • treatment for pain and suffering • information about hospital ethics policies • participate in your treatment decisions, including ethical decisions about

treatment • refuse or accept treatment or research that is offered to you. This includes the

right to refuse treatments that can potentially help prolong your life, such as mechanical breathing machines, dialysis, artificial nutrition/hydration or attempted cardiopulmonary resuscitation (CPR)

• complete advance directives such as a living will or medical power of attorney. • privacy, confidentiality, security and culturally respectful communication • have access to items, devices, and/or a language interpreter to assist with

conversations about your health throughout your visit free of charge • decide who may visit you during your hospital stay • choose a primary support person to stay with you during your hospital stay • be informed if family or guest visitation must be restricted • freedom from mental, physical, sexual or verbal abuse or neglect • a discharge planning evaluation to be sure your health care needs are met after

you leave the hospital With your rights come certain responsibilities. Your responsibilities, among others, include: • the responsibility to give your health care team honest and accurate information

about your medical history • the responsibility to follow treatment directions and cooperate with your health

care team • the responsibility to treat other patients, visitors, your health care team and

hospital property with respect

Who is on my health care team? Throughout this guide we refer often to your health care team. Depending on many factors, your health care team may be made up of any number of individuals. Every team member brings special expertise. These individuals will identify themselves, their professional status if applicable, their relationship to others on the team, and their role in your treatment and care.

Goals and types of treatment The most basic goal of medicine is to fix or cure your health problem. If a complete cure is not possible, the goal of the health care team is to try to slow down the problem or make it go away for a while (remission). Perhaps the most important goal is to provide you with comfort and relief of suffering at all times. You will receive medically appropriate treatment to meet these goals and we hope that you will do well.

Communicating with your health care team Good communication is essential to every part of medical treatment. It is important when things are going well. It may be even more important when things are not going well and the outcome you and your family expected is not being achieved. Either way, it is vital that you, your family and your health care team communicate clearly. You should feel free to discuss any topic associated with your care and treatment with members of your health care team. For example, you may want to discuss: • your diagnosis • goals of your treatment • the types of treatment appropriate to meet those goals • the benefits, burdens, and risks of treatment as well as the probability of success It is important that you discuss your goals and the types of treatment with your physicians, nurses and your family while you are able to speak for yourself. How do you want to be treated if you have an accident or an illness and become so sick you can’t speak for yourself? Who should speak for you and what should they say?

The importance of advance care planning The process of thinking about who should speak for you if you can no longer speak for yourself and considering the goals and intensity of your treatment is called advance care planning. When thinking about who should speak for you, consider how trustworthy that person is and how available they are. Think about what you would want them to say on your behalf. This is easy if you are only temporarily unable to speak for yourself and recovery is expected. But what if you become so sick that you can no longer communicate and cure is no longer possible? If you make these decisions in advance, you will be relieving your family and loved ones from making these decisions for you. You should think about these questions: • What physical, mental or financial burdens would you be willing to accept to

temporarily stay alive longer (or prolong dying) in that circumstance? • What quality of life would you want to have to make staying on a breathing

machine or dialysis worthwhile? • Would you be willing to live confined to a bed in a nursing home, unable to care

for yourself?

• How important is pain control to you—not only physical, but mental and spiritual?

• What if you were permanently unconscious and could not feel pain, hunger, thirst, happiness, love or joy, but could be kept alive with a tube in the stomach to provide artificial nutrition and hydration?

These are hard questions and they often have deeply personal answers. Whatever your answers are, the best way to communicate them is by completing an advance directive such as a Living Will and/or a Medical Power of Attorney. Advance directives have been clearly shown to improve patient care in the setting of serious illness and to lessen family stress. If you do not have an advance directive at the time of admission, we hope you will complete one prior to discharge. It is never too late to do so, and a copy can be placed in your medical record. You are not required to complete an advance directive. Whether or not you choose to complete an advance directive, your care, treatment and services that you receive will not be affected, nor will your decision result in any discrimination against you. To help you face questions you may have about advance directives and to complete an advance directive, you may request the following additional resources from your nurse, social worker, chaplain or physician, or you may access all of the following documents online at www.BaylorHealth.com/ PatientInformation.

• Advance Care Planning • A Guide to Your Care

A GUIDE TO YOUR CARE

2

BHVH-1101 (Rev. 11/14)

• Common Questions and Answers About Artificial Nutrition and Hydration • Common Questions and Answers About Autopsies • Common Questions and Answers About Cardiopulmonary Resuscitation (CPR) • Common Questions and Answers About Hospice • Common Questions and Answers About Pain in the Setting of Serious Illness • Common Questions and Answers About Palliative Care • Common Questions and Answers About Severe Brain Injury • Information About Serious Illness • Official State of Texas forms for a: Living Will (Directive to Physicians and

Family or Surrogates), Medical Power of Attorney, Notice of Declaration and Declaration for Mental Health

• Out-of-Hospital Do-Not-Resuscitate Order • Simplified Advance Care Plan and Living Will

If I complete an advance directive, can I change my mind? Yes, you may cancel any advance directive simply by destroying the document, signing and dating a written statement that states your desire to cancel the directive, or telling your doctor or nurse. You may also review and revise your advance directive. If you choose to change an advance directive, you must execute a new one.

Where else can I get help? In addition to your personal physician, all Baylor Scott & White Hospitals have specially trained social workers, nurses, and chaplains who can help you with advance care planning concerns. You may also have ethical concerns as you consider potentially serious issues. All Baylor Scott & White Hospitals have access to ethics committees and ethics consultants who may offer counsel and assist in resolving ethical issues that might arise. These services are provided free of charge. You, your family or health care decision maker, your physician or any member of your health care team may request guidance from a Baylor Scott & White Hospital ethics committee. For further information, your physician, nurse, social worker or chaplain can help you reach the ethics committee at your facility or you may call one of the phone numbers at the end of this handout. You may also wish to consult your personal or family lawyer if you have questions about advance care planning. What if there is disagreement about ethical issues? On rare occasions there may be ethical disagreements between you, your family and/or health care providers. We believe good communication can prevent most ethical disagreements. It is also worth remembering the following:

• We will make every reasonable attempt to honor your treatment preferences within the mission, philosophy and capabilities of Baylor Scott & White Hospitals and the accepted standards of medical practice. This includes those expressed by an advance directive or by others on your behalf if you lack an advance directive and are unable to make decisions.

• We respect your right to reject treatments offered. • We do not recognize an unlimited right to receive treatments that are medically

inappropriate. • Texas law, specifically Chapter 166 of the Texas Health & Safety Code, provides

a process for resolving ethical disagreements between you, your family, and/or health care providers in those rare cases where further communication does not resolve the disagreement. This process relies on ethics consultants and ethics committees available at each Baylor Scott & White Hospital to help as needed.

At some point, you may be asked to make hard choices about treatment when cure of your illness is no longer possible and emotions may be strong. We have provided this information in hopes of helping you better understand your rights, responsibilities and ethical issues associated with being in the hospital. We hope a better understanding will improve communication, treatment and lessen stress for all.

Complaints We welcome your feedback at all times, both positive and negative. If you have any complaints, we hope you will: • First report your complaint to the clinical manager for the unit or facility involved.

The bedside nurse will help you identify the clinical manager.

• You may also contact hospital administration at the number listed in the Contact Information contained in this document.

• We will investigate your complaint through our formal complaint process and we will give you a response. Although we encourage you to bring your concerns directly to us, you always have the right to take any complaint to the Texas Department of State Health Services and/or the Joint Commission by e-mail, fax, letter or phone at the contact numbers and addresses listed below.

Grievance Process Information THE JOINT COMMISSION:

E-mail: complaint@jointcommission.org

Telephone: (800) 994-6610 weekdays 8:30 a.m. to 5 p.m., Central Time

Fax: (630) 792-5636 Office of Quality Monitoring

U.S. Mail: Office of Quality Monitoring The Joint Commission One Renaissance Boulevard Oakbrook Terrace, IL 60181 TEXAS DEPARTMENT OF STATE HEALTH SERVICES: If you have any complaints concerning the information that we have provided in this document, you may contact the Texas Department of State Health Services at (888) 973-0022 (toll free number). 1100 W. 49th Street Austin, TX 78756-3199 BAYLOR JACK AND JANE HAMILTON HEART AND VASCULAR HOSPITAL Administration: (214) 820-0695 Pastoral Care/Chaplain: (214) 820-2542 Guest Representative: (214) 820-0629 Public Safety: (214) 820-4444 Patient Privacy or Confidentiality Complaints: (866) 245-0815

Billing Concerns: (214) 820-3151 or (800) 725-0024

Understanding

your health

just got easier

Doctor-prescribed education

Doctors try to explain everything about your health but sometimes it gets confusing. Emmi programs help to answer your questions and make you feel more at ease. You are the most important member of your health care team, so you should have all the information you need.

What are Emmi programs?

Emmi® is a series of free, animated online programs that walk you through important information

about a health topic, condition or procedure. You can watch Emmi programs as many times as

you like and you can share them with your family and friends.

Sample screen shots from Emmi programs

Need help?

Email: support@emmisolutions.com

Call: 866.294.3664

© 2013 Emmi Solutions, LLC Cardiology program © 2013 Emmi Solutions, LLC Cardiology program

Ready to learn more?

Your Emmi program will be coming from the Baylor Heart and Vascular Services at Dallas

PRE-REGISTRATIONOnline

PRE-REGISTER ONLINE AT:

BaylorHeartHospital.com/Pre-Admission-Registration.html• Log on to the Internet and go to BaylorHeartHospital.com/Pre-Admission-Registration.html

• You will be able to establish your own secured sign-on.

• Complete all blanks on the form. Be sure to indicate the Baylor facility where you are scheduled for services. Upon completion, click on the enter button.

• Your pre-registration information will be stored and accessible to you for future visits. You will only need to update the new visit information and any personal information changes three days before your procedure.

ITEMS TO HAVE ON HAND FOR PRE-REGISTRATION:• Contact information for your insurance carriers, including policy number, group name and number,

address and phone number. (This information may be found on your insurance card.)

• The name of the doctor who is admitting you.

• The date your procedure is scheduled.

• Emergency contact information - name, address and phone number of someone who could be contacted in the event of an emergency.

SAVE TIME! Pre-register online at BaylorHeartHospital.com/Pre-Admission-Registration.html

If you need technical assistance during the online pre-registration process, please call us at 1.877.810.0372. If you have any questions related to your visit, please call us between 8 AM – 4:30 PM, Monday through Friday, at 214.820.0621. We look forward to serving you.

At Baylor Heart and Vascular Hospital, your time and convenience is important to us. That’s why we offer online pre-registration for your upcoming procedure. Pre-registering online at least two business days prior to your scheduled visit helps make the check in process for your appointment quicker.

© 2013 Baylor Health Care System. BHVH_538_2013 RT