CENTER FOR WOMEN S SEXUAL HEALTH
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1 Welcme t the Center fr Wmen s Sexual Health- The ffice f Dr. Stephen C Dalm and Physician Assistants Nisha McKenzie and Erin Walker, as well as Physical Therapist Lily Dawsn. Thank yu fr chsing ur ffice! We lk frward t having yu as a patient. Enclsed yu will find the paperwrk that must be filled ut and brught alng with yu t yur first appintment. If yu take any medicatins, please list them alng with their dsages, r feel free t bring them with yu t the appintment. Due t federal regulatins, yu must be able t prvide yur current insurance card at every appintment, alng with a pht ID. Withut these cards we will nt be able t see yu r yu may be respnsible fr payment at the time f service. If yu d nt have a picture ID, r if yur driver s license des nt shw yur current address, yu must als bring alng a utility bill shwing yur current address. If yu are under the age f 18, yur parent r guardian must prvide these items. Please call with any insurance questins. We d nt accept any Medicaid r Medicare plans (r if yur cverage changes t either if yu are a new patient t us). Yu will be expected t pay any cpays that are required by yur insurance at the time f the appintment. It is yur respnsibility t knw and understand yur insurance, including deductibles and cpays. Please take the time t learn abut yur cverage prir t yur visit, as ffice visits and labs may apply. Please cntact us at least 24 hurs prir t yur appintment time if it will nt wrk fr yu, r a n shw fee f $75.00 may apply. We use Mercy Health St Mary s Hspital and Grand Valley Surgical Center fr surgeries. If yu have any questins, feel free t call Yur appintment is scheduled fr Please plan fr yur first appintment t be apprximately 1 hur.
2 Patient Infrmatin Name: Date f Birth: Age: Address: Hme Phne ( ) Wrk Phne ( ) Cell Phne ( ) May we crrespnd with yu via ? If yes, (When ding s, please place yur name in the subject line f each ) SSN# (required) Spuse/Guardian s name (if applicable) Driver s License # Race: (Circle) Hispanic Nn-Hispanic Circle all that apply: Married Widwed Separated Partnered Single Remarried Divrced Plyamrus Referring Physician: Primary Care Physician: Emergency Cntacts: Name: Relatinship: Phne#: Name: Relatinship: Phne#: Emplyment Status (Circle): Emplyed Unemplyed Retired Self-Emplyed Student Emplyer Occupatin Address Respnsible Party (If patient is a minr): Name: Date f Birth Relatinship Address Primary Phne: Secndary Phne: Authrizatin: I authrize the release f medical infrmatin t my primary care r referring physician, t cnsultants if needed and as necessary t prcess any insurance claims, insurance applicatins and prescriptins. I als authrize payment f medical benefits t the physician. Signature Date
3 Wh may we thank fr referring yu t ur ffice? Insurance & Financial Plicy Yu may receive billing ntices frm ur partnering cmpany, Grand Rapids OB/GYN. Yu will nt be billed frm bth cmpanies. We make every effrt t address and cde such things that are typically cvered by mst cmmercial insurance plans. Hwever, given the nature f many tpics discussed, sme insurance cmpanies may deny cverage, and therefre decline payment. These decisins are, unfrtunately, ut f ur cntrl. If a claim is denied fr any reasn, yu will be required t make the payment within 30 days. Denied claims will nt be resubmitted unless it is deemed abslutely necessary. If yu are seen fr future visits fr the same issue, payment will be requested at time f service. We are hpeful that this will change in the near future, and that insurance cmpanies will realize that female sexual health is just as imprtant as male sexual health, and mre s, that it is imprtant t a wman s verall health. We appreciate yur trust in ur care and yur help in trying t make imprtant changes in the ever shifting landscape f health care. In the unfrtunate event that yur accunt is turned ver t ur Cllectin Agency a 30% fee will be billed t yur accunt. By signing belw, I hereby agree t and understand the financial plicy fr the Wmen s Center fr Sexual Health. Signature Date: Insurance Infrmatin: (If yu have a secndary insurance, please ntify the frnt desk upn arrival) Type: Cntract #: Name f insured: SSN# DOB
4 The fllwing cnsent is required by the Department f Health and Human Services in accrdance with the Health Insurance Prtability and Accuntability Act f 1996 (HIPPA). CONSENT FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI) Prtected Health Infrmatin r PHI is any infrmatin that is unique t yu. It includes any persnal infrmatin abut yu and yur health care. I authrize the use and disclsure f my PHI fr purpses f treatment, payment, and daily healthcare peratins which include but are nt limited t: the crdinatin f healthcare services between prviders f such services; services with insurance cmpanies regarding payment, reimbursement, premiums, eligibility, cverage, and utilizatin review; third party cllectrs and cnsumer reprting agencies. I have been ffered a cpy f the Ntice f Privacy Practices. I understand that I may review the ffice s Ntice at any time. I understand the Ntice may change and that I may request a revised Ntice. I understand that I may request restrictins be placed n disclsure f my PHI, but that The Center fr Wmen s Sexual Health is nt bligated t cmply with my requests, unless they agree t my restrictins in writing. I understand that I have a right t revke the cnsent, in writing, t the extent that The Center fr Wmen s Sexual Health has nt yet taken any actin in reliance upn the cnsent. The Center fr Wmen s Sexual health has always prtected yur persnal infrmatin and we will cntinue t d s. If fr any reasn yu are nt willing r able t sign the cnsent, then we will be unable t enter int a physician/patient relatinship with yu. Please list any persns whm yu authrize us t discuss r release medical infrmatin and /r test results with: (Authrizatins will remain in effect until remved) Date f Authrizatin Signature Date
5 Tday s Date / / Name Date f Birth / / D yu have any medicatin allergies? Y N If yes, please list: Please list any clse relatives with a histry f the fllwing medical cnditins: Relative Relative Breast Cancer Diabetes Ovarian Cancer Heart Attack (Strke, Bypass, Ect) Uterine Cancer Fibrmyalgia Cln Cancer Depressin High Bld Pressure Endmetrisis PCOS (Plycystic Ovarian Syndrme) IC (Interstitial Cystitis) CPP (Chrnic Pelvic Pain) IBS (Irritable Bwel Syndrme) Please add any additinal details abut yur selectins belw:
6 Have yu ever been diagnsed with any f the fllwing illnesses? Circle all that apply. Anemia Bld Clts Chicken Px High Bld Pressure Bladder Infectin Diabetes Fibrcystic Breasts Strke Bleeding Issues Pelvic Infectin Migraines Depressin Anxiety Drug/Alchl Abuse Thyrid Prblem Genetic Cnditin Cancer Endmetrisis Ovarian Cysts Uterine Fibrids Date Diagnsed: Type (if applicable): Bld Transfusin Abnrmal Pap Sickle Cell Osteprsis Added Details: OB Histry - Are yu currently pregnant? Year f Birth M r F Weight f Baby Delivery Type Cmplicatins Age Gyn Histry: Age at 1 st perid: Are yu still menstruating? If n, at what age was yur last perid? Cycle length # f days yur perid lasts fr Are yur perids (Circle all that apply): Regular r Irregular Painful/ Bthersme r Nt Bthersme Light Light t Mderate Mderate t Heavy Very Heavy
7 Are yu currently sexually active? Yes N Have never been sexually active Are yu sexually attracted t: Men Wmen Bth Other: If applicable, what prnuns d yu use? She/Her He/Him They/Them Other: Number f Lifetime sexual partners? Are yu currently n birth cntrl? What Kind? Have yu ever been diagnsed with a Sexually Transmitted Infectin? If yu answered yes t the abve questin, please list all infectins that yu have been diagnsed with in yur lifetime: Date f last pap smear Were results nrmal r abnrmal? Date f last mammgram Were results nrmal r abnrmal? Please list all surgeries & the year they were perfrmed: Have yu ever had any f the fllwing vaccinatins? If yes, please list the date f last injectin. TDap (Tetanus) Gardasil (HPV) Series Flu Sht D yu currently smke cigarettes? Hw many per day? Are yu a frmer smker? When did yu quit? D yu chew tbacc? D yu use E-Cigarettes? D yu currently drink alchl? # f drinks per week?
8 D yu currently use any recreatinal drugs? Never used Used in the past but nt anymre Check all that apply: Marijuana Amphetamines Herin Barbiturates Opiates Ccaine Others: D yu currently exercise? Hw ften & what type? D yu have a histry f physical, sexual r emtinal abuse? If yes, are yu safe nw? Did yu attend cunseling fr the abuse? Please list all medicatins yu are currently taking, including supplements, vitamins & herbs: Please add here any additinal pertinent infrmatin yu wuld like the prvider t knw regarding yur visit with us tday:
9 Pelvic Pain Histry (If yu have n issues with pelvic pain, yu may skip this sectin.) Please describe yur pain (use a separate sheet f paper if needed): What d yu think is causing yur pain? Is there an event yu assciate with the nset f yur pain? If s, what? Hw lng have yu had this pain? : mnths years Please check all instances belw that relate t r cause yur pelvic pain: Pain with start f cycle Pain at vulatin (mid cycle) Pain (nt cramps) befre perid Pain in grin when lifting Deep pain during intercurse Pain lasting hurs r days after intercurse Pain when bladder is full Other muscle r jint pain: Pain just after perid is ver Burning r vaginal pain after intercurse Pain with urinatin Back pain Pain when sitting Cping: Hw d yu cpe with yur pain? Wh are the peple yu talk t cncerning yur pain, r during stressful times? (Example: Dctr, friend, church grup, spuse, etc.)
10 What types f treatments have yu tried in the past fr yur pain? What type f prviders have yu already seen? Check all that apply. Acupuncture Anti-Seizure Medicatins Antidepressants Bifeedback Btx injectins Cntraceptive Pills/Ring/Patches Danazl (Dancrine) Dep-prvera Herbal Medicine Hmepathic Medicine Luprn, Synarel, Zladex Massage Meditatin Narctics Nerve Blcks Physical Therapy Surgery Skin Magnets TENS unit Trigger pint injectins Nutritin/Diet Changes Gyneclgist Family Practitiner Neurlgist/Neursurgen Psychiatrist Rheumatlgist Urlgist Ur-gyneclgist Other Prvider: What physicians r health care prviders have evaluated r treated yu fr yur chrnic pelvic pain? Physician/Prvider Name Specialty City/State/ Phne number
Welcome to the Center for Women s Sexual Health- The office of Dr. Stephen C Dalm and PA Nisha McKenzie.
Phne (616) 591-9100 Fax (616) 247-3679 Welcme t the Center fr Wmen s Sexual Health- The ffice f Dr. Stephen C Dalm and PA Nisha McKenzie. Thank yu fr chsing ur ffice! We lk frward t having yu as a patient.
Your appointment with our office is scheduled on
Grand Rapids OB/GYN Dr Stephen C Dalm Nisha McKenzie PA-C Erin Walker PA-C 5060 Cascade Rd SE Ste C Grand Rapids, MI 49546 Phone (616)247-1700 Fax (616)247-3679 www.grandrapidsobgyn.com Welcome to Grand
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