*First Heterosexual Decline to Answer Middle Homesexual American Native *Last Bisexual Asian Suffix Other Black Previous First Don't Know Hispanic Previous Last Decline to Answer Pacific Islander *Date of Birth White Unknown *Mailing Address *Marital Status: *Employment: Address1: Never Married Employed Address 2: Married Unemployed City: Annulled Full-time Student State: Polygamous Part-time Student Postal Code: Domestic Partner Other Widow Retired Name: Separated Child Phone: Divorced Occupation: Address1: Interlocutory City: State: Zip: DEMOGRAPHICS Patient Name *Orientation: *Race Citizenship Country: SSN or National ID: Employer: *Emergency Contact: First: Middle: Patient Contact: Phone: Home Phone: Relation to Paitent: Work Phone: Address1: Work Ext: Cell Phone City: Email State: Zip: Electronic notification preference (ie appointment reminders): email Text Phone Written notification preference: email Postal If someone other than the patient will be making healthcare decisions, please complete the following Type: Primary Caregiver Legal Guardian Healthcare Proxy First Address1 Middle Address2 Last City Phone State Relation to Paitent Zip Primary Care Provider: Last Seen By PCP: Preferred Pharmacy: Referred By: Last:
Patient Name: Primary Insurance: Effective: *Payer Name: Plan Name: Group Number: Insured's ID Number: INSURANCE Is the patient the primary insured? Yes No If no, complete the following: Relation to Patient Spouse Child Other *First Name: Middle Name *Last Name *Insured's DOB Insured's Sex Insured's Mailing Address: *Address1: *City: *State: *Zip: *Country: *Home Phone Secondary Insurance: Effective: *Payer Name: Plan Name: Group Number: Insured's ID Number: Is the patient the primary insured? Yes No If no, complete the following: Relation to Patient Spouse Child Other *First Name: Middle Name *Last Name *Insured's DOB Insured's Sex Insured's Mailing Address: *Address1: *City: *State: *Zip: *Country: *Home Phone Is patient the Guarantor? Yes No If no, please ask for a Guarantor Information Form
*Patient Name Why are you here today? Any other current problems? MEDICAL Allergies: Food Drug Latex Other Current Medications: Name: Dose: Frequency: Anyone in the family with the following disease? Relation to Patient Alive? disease? Relation to Patient Alive? High Blood Pressure Y N Diabetes Y N Heart Problems Y N Cancer Y N Thyroid Issues Y N Stroke Y N Colon Disease Y N Mental Illness Y N Birth Defects Y N Other Y N Received HPV vaccination? Y N When? # of shots? Have you ever had any of the following? Ectopic Pregnancy Y N Hyperlipidemia Y N Osteopenia Y N Congestive Heart Failure Y N Hypertension Y N Osteoporosis Y N Coronary Artery Disease Y N Migraine with Aura Y N Polycystic Ovarian Syndrome Y N Diabetes Mellitus Y N Migraine without Aura Y N Prediabetes Y N Gastroesophageal Reflux Y N Morbid Obesity BMI > 40 Y N Former Smoker Y N Gestational Diabetes Mellitus Y N Obesity BMI > 30 Y N Other: Current Contraception? Complications from birth control? Y N Historyof Genetic Disease? Y N High Risk Pregnancy Factors? Y N First day of last period? Was it normal? Y N Do you have regular cycles? Y N How long do they last? Normal flow is: Scant Light Normal Heavy With clots With mild cramps With severe cramps Ever used hormone contraception to control bleeding? Y N Frequency of periods in days? Have you gone through menopause? Y N Age at start? Screenings Date: Abnormal ever? What was abnormality? Procedure/Surgery to treat: Last Pap Smear: Y N Last Mammogram: Y N Last Colonoscopy: Y N Last Dexascan: Y N Osteoporosis Osteopenia Infection You have: Partner has: Partner exposed to: Tuberculosis Y N Y N Y N Genetial Herpes Y N Y N Y N Hepatitis? Y N Y N Y N History of STD Y N Y N Y N (Gonnorrhea, Chlamydia, HPV, HIV, Syphillis, Trichomonas, other) Rash or viral illness since last menstrual period? Y N
Obstetrics History Total Pregnancies Full Term Premature MEDICAL Miscarriages Abortion Ectopics Multiple Births Still Living Date Gestation Weeks Labor Hours Birth Wt lbs/oz Sex M/F Type Type of Anestesia Place of Pre-Term Y / N Complications Y / N Sexual History Currently Sexually Active? Y N How long with current partner? Any outside partners during current relationship? Y N Sex with: Male Female Both Age of first intercourse? How many partners in the last year? Any additional methods of birth control? Y N How often is method used? What do you use to prevent STD infections? Ever diagnosed with an STD? Y N If yes, list: Partner diagnosed with an STD? Y N If yes, list: Last test for HIV? Last test for STDs? Received HPV vaccine? Y N Social History Regular Exercise? Y N Tobacco User? Y N Alcohol consumption? Y N Substance Ever used any illegal or street drug? Y N If yes, list below: Drug: Duration of use Frequency used: Method of delivery: Surgical History (including C-section): Month Year
CONSENT FOR TREATMENT: By signing this form, I consent to and authorize my health care provider to examine and treat. I understand that this could include lab tests, education, or other diagnostic procedures. I understand that my provider is available to explain the purpose of the procedures and treatment, and that I have the right to refuse the recommended treatment. ELECTRONIC PRESCRIBING: I authorize Center for Women s Health to retrieve my medication history through their e-prescribing system and then import it into my electronic medical record. BILLING AUTHORIZATION: I hereby authorize Center for Women s Health to release requested medical information to my insurance company to collect payment for any charges incurred. ASSIGNMENT OF BENEFITS: I hereby request that payment of insurance benefits be made directly to Center for Women s Health on my behalf for any services provided to me. I acknowledge and understand that I am financially responsible for all charges relating to the service(s) rendered to my dependent or myself. If, for any reason, my insurance carrier (including Medicaid or Medicare) does not pay any portion of my bill, I agree to pay my portion promptly. PATIENTS RIGHT TO PRIVACY: I acknowledge I have been made aware of Center for Women s Health privacy practices, which are posted in the reception area. If I would like a copy of the HIPAA notice, it is my responsibility to ask for one. DISCLOSURE OF PRESENCE: I understand that during my visit my friends, family, employers or others may call to inquire about my presence at Center for Women s Health. I authorize you to disclose information about my presence at this facility to the following people: Name Relation to Patient COMMUNICATION OF CARE: I hereby authorize Center for Women s Health to verbally communicate regarding my care with: Name Relation to Patient Print Name Signature Date