IN CASE OF AN EMERGENCY NOT LIVING WITH YOU
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1 GENERAL INFORMATION Name (as it appears on insur card) Address City State Zip Home phone Cell Marital status DOB SS# Employer Work # Parent name (if minor) IN CASE OF AN EMERGENCY NOT LIVING WITH YOU Name Phone # Relationship to you INSURANCE INFORMATION Name of insured DOB Primary Insurance Member ID Group # Secondary insurance Primary Insurance Member ID Group # Who referred you?
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3 Health History Social History Do you smoke? YES NO How much? How many years? Do you use others drugs? NO YES If yes; what kind? Do you have any history of physical, emotional, sexual abuse? YES NO Age at first intercourse? Do you have any new partners? How many different sex partners have you had? Were your partners(circle): Men Women Both How long have you been with your current sex partner? What type of sex have you had in the past? (Circle) Vaginal Oral Anal Other No Sex Do you have symptoms of a genital infection? NO YES (Circle all that apply) Discharge Odor Burning Rash Bumps Sores Irritation Itch Vaginal Dryness Pain with sex Bleeding after sex Other Would you like STD testing? YES NO Have you ever had a sexually transmitted disease or genital infection? NO YES (Circle the ones you might have had): Chlamydia Gonorrhea Herpes Genital Warts PID Syphilis HIV BV Trichomonas Hepatitis B or C Yeast SYSTEMS REVIEW- (Check any of the following that you have now or have had in the past six months.) Anxiety Weight gain/loss Loss of consciousness Varicose veins or easy bruising Fatigue Numbness or tingling Ringing in ears Headaches, dizziness Hot flashes or night sweats Chronic cough or coughing Visual changes Bloody or black stools Chest pains, shortness of breath Diarrhea, constipation, changes in stool Changes in skin or hair Abdominal pain, Nausea, or vomiting GYNECOLOGICAL HISTORY Age at first period Date of last menstrual period Previous period Duration of flow is Days. Flow is Light Medium Heavy Do you have pain with periods? YES NO
4 When was your last Pap smear/yearly exam? Was it normal? Have you ever had an abnormal pap? Has it been seven years without a pap smear? v15.89 Have you had three consecutives negative (normal) pap smears? 795.0x FECAL/URINE HISTORY Do you ever leak urine when you cough or sneeze? Do you frequently have a sudden urge or need to urinate? Do you have problems with urinating frequently at night or bed- wetting? Do you have painful urination or difficulty in starting urinating? Do you ever have protrusion or bulging sensation from your vagina? If age 50 or over; When was your last colonoscopy? Do you have any stools problems or fecal inconstancy? BREAST HISTORY Have you had any nipple discharge? YES NO Do you have breast implants? YES NO Do you have monthly self- breast examinations? YES NO Have you had abnormal mammograms? YES NO Date of your last mammogram CANCER HISTORY Breast cancer before age 50 YES NO Male breast cancer at any age YES NO Ovarian cancer at any age Bilateral breast & ovarian cancer YES NO 2 or more breast cancer in the family YES NO Endometrial cancer before age 50 YES NO Colorectal cancer before age 50 YES NO Colorectal cancer after age 50 YES NO Family member with any of the following cancer Colocteral Ovarian Endometrial Sebaceous adenoma Biliary Tract Small Tract Small bowel Pancreas Kidney Brain Stomach Ureter/Renal Pelvis
5 OBSTETRICAL HISTORY Number of times pregnant? Number of children living Number of miscarriages Number of abortions If trying to get pregnant- How long? Month(s) Year(s) Date Delivered Weeks pregnant Delivery at Birth weight Vaginal/ Cesarean Delivery Sex Complications/Comments GENETIC HISTORY Patient s age 35 years or older as of EDC? NO YES Thalassemia? NO YES Neural Tube Defect? Meningomyelocele, spina bifida, or anencephaly NO YES Congenital Heart Defect? NO YES Down Syndrome? NO YES Tay- Sachs? NO YES Canavan Disease? NO YES Familial Dysautonomia? NO YES Sickle Cell Disease or Trait? NO YES Hemophilia or other blood disorders? NO YES Muscular Dystrophy? NO YES Cystic Fibrosis? NO YES Huntington s Chorea? NO YES Mental Retardation/Autism? NO YES Other inherited genetic or chromosomal disorder? NO YES Maternal metabolic disorder? NO YES Patient or baby s father had a child with birth defects not listed above? NO YES Recurrent pregnancy loss or stillbirth? NO YES Medications(including supplements, vitamins, herbs, or OTC drugs)since LMP? NO YES HOSPITALIZATIONS List all hospitalizations including operations you have had in the past. DATE HOSPITAL REASON Have you had blood transfusion? YES NO History of HIV? NO YES
6 ILLNESSES Have you or any blood relatives had any of the following? Arthritis Asthma Birth Defects Bleeding disorder Blood clots Colon polyps Depression Diabetes Down syndrome Epilepsy Hay fever Heart problems High blood pressure High cholesterol Kidney problems Liver or Gallbladder Stroke Thyroid problem Breast cancer Colon cancer Ovarian cancer Uterine cancer Other cancer Other YOU FAMILY RELATIONSHIP Current Medications Drug Allergies Pharmacy name and number Patient Signature Date
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