Welcome to our Practice

Transcription

1 Welcome to our Practice The staff of Akron General Obstetrics & Gynecology is pleased that you have chosen us to provide your women s health care. Please know that your health is our primary concern and we look forward to partnering with you in your care. Our providers work collaboratively to supply a wide range of women s health services. No matter what the service, it is our mission to improve the health and lives of the people and communities we serve by providing highquality, comprehensive care in a respectful and dignified manner. In order to expedite the new patient registration process, we ask that you read and/or complete the following forms: Patient Registration/Intake Form Medical Health History Office Policy Notice to Patients Acknowledgement of Receipt of Notice of Privacy Practices For your first appointment, please bring completed copies of the above forms, as well as: Insurance card(s) Photo ID Current medications Co-payment (if required by your insurance) For new patients, we respectfully ask that you arrive 15 minutes prior to your scheduled appointment time in order to complete the registration process. In consideration of all of our patients, any patient who arrives 10 minutes after his or her scheduled appointment time may be asked to reschedule. Our office hours are: Monday - Friday: 8 a.m. 5 p.m. Phones: Phones are answered during office hours. If you have a non-life threatening emergency after office hours, please call our office at and the answering service will page the appropriate physician. If you are having an emergency, please call 911. Again, thank you for choosing us. We look forward to seeing you at Akron General Obstetrics & Gynecology and will do our best to make your visit as pleasant, efficient and complete as possible. Sincerely, The Providers and Staff of Akron General Obstetrics & Gynecology 1

2 PATIENT REGISTRATION/INTAKE FORM Patient s legal name: Last First M.I. (Maiden) Preferred or other known-by name: Home address: Street City State Zip Social Security number: / / Date of birth: / / Sex: F o M o Home phone: ( ) Cell phone: ( ) Work phone: ( ) ACKNOWLEDGMENT OF RECEIPT OF ADVANCE DIRECTIVE INFORMATION (Living Will or Power of Attorney) An advanced health care directive, also known as living will, personal directive, advance directive or advance decision, is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. In the U.S., it has a legal status in itself, whereas in some countries it is legally persuasive without being a legal document. Please initial after each statement: I have completed an ADVANCE DIRECTIVE for health care: o_yes o No If yes, please indicate which: o Living Will o Durable Power of Attorney I am requesting information regarding ADVANCE DIRECTIVES: o_yes o No Patient Signature: Date: 2

3 INSURANCE INFORMATION Primary Medical Insurance Insurance Carrier: Carrier s Phone Number: Policy #:_ Group #:_ Subscriber: Subscriber s Soc. Sec. #: Relationship to Patient: Secondary Medical Insurance If you are currently uninsured please complete the following: Person responsible for payment: Name: Last First M.I. Relationship Address: Street City State Zip Certification Statement: I certify that the information above is true and accurate to the best of my knowledge. Name of Patient (Print) Name of Responsible Party (Print) Signature of Responsible Party Signature Date Responsible Party Driver s License # 3

4 OFFICE POLICY NOTICE TO PATIENTS We strive to provide you the best personalized care available. To make this possible, we adhere to a set of very important guidelines. Please read them carefully, initial all the lines and indicate your agreement by signing at the bottom. Late Policy: Being 15 minutes late for an appointment may require you to either reschedule or wait for an available opening. There are no guarantees since openings due to cancellations or no-shows are unpredictable. We do not allow appointment overlap because this undeservedly compromises the care of another patient. Three (3) Hour Advance Notice: If you wish to change or cancel an appointment, we ask that you please provide a three (3) hour advance notice. This allows us to offer your appointment to another patient who may be waiting to see a physician. We understand, however, that emergencies can and do happen, and will make every attempt to work with you. No-show Policy: If you miss your appointment without notice or provide less than a three (3) hour advance notice, it will be considered a no-show. Again, though, we understand that emergencies can and do happen, and we will work with you in the event of an unexpected or last-minute emergency. Akron General Obstetrics & Gynecology adheres to a strict policy stating that any patient with three (3) no-shows within a 12-month period will have all future appointments removed from the schedule and will be dismissed from the practice. Pain Medications: The physicians at Akron General Obstetrics & Gynecology are not pain management providers and therefore do not guarantee any form of pain medications and/or narcotics. If you have a chronic condition that requires long-term use of such medications, please be advised we will refer you to a pain management clinic for treatment of the chronic condition. Insurance/Co-Pays: Please bring updated insurance and co-payment to every visit. Failure to make co-payment at the time of visit could result in cancellation of the scheduled appointment. Patients are responsible for charges not covered by insurance. Missing proper identification: Patients who present to the office without valid photo ID, proper insurance information or missing insurance information, may be asked to reschedule. Self-pay: If you are a true self pay patient without insurance, a 20 percent discount will be applied to your office visit. If, for any reason, you have insurance but request an office visit be processed as a self-pay you will not be eligible for the discount. Patient signature: Date: 4

5 REVIEW OF CURRENT SYMPTOMS Current Problems Please check all that apply. General Respiratory Breasts o Fever o Cough o Lumps or masses o Chills o Difficulty sleeping o Nipple discharge o Sweats o Wheezing o Tenderness o Weight Gain o Other o Other o Other Gastrointestinal Neurological Eyes- circle right, left or both o Nausea o Headaches o Vision changes (R/L) o Vomiting o Difficulty Seizures o Eye injury (R/L) o Diarrhea o Weakness or numbness o Eye irritation (R/L) o Abdominal pain o Other o Other o Bloody stools o Other Psychological Ears- circle right, left, or both o Depression o Hearing loss (R/L) Genitourinary o Anxiety o Earache (R/L) o Pain with urination o Other o Other o Frequent urination o Difficulty starting or Endocrine Mouth and Throat maintaining urination o Cold intolerance o Sores in mouth o Sexual difficulties o Heat intolerance o Difficulty swallowing o Other o Excessive thirst or urination o Sore throat o Other o Other Musculoskeletal o Muscle cramps or aches Hematological Cardiovascular o Joint pain or swelling o Abnormal bruising o Chest pain o Back pain o Abnormal bleeding o Shortness of breath o Other o Other o Swelling of hands or feet o Other Skin Allergy o Rash o Seasonal allergies o Itching o Other o Suspicious lesions o Other 5

6 MEDICAL PATIENT/HEALTH HISTORY Last Annual Exam: / / Result: Last Pap Smear: / / Result: Last Mammogram: / / Result: Last Osteoporosis Screen: / / Result: Last Colonoscopy: / / Result: Last Diabetes Screen: / / Result: Last Thyroid Test: / / Result: Update Date Date Date Date Initials Initials Initials Initials Past Obstetrical History How many times have you been pregnant? How many deliveries have you had? How many miscarriages? Abortions? Tubal pregnancies? Living children? How many, if any, were premature? How many weeks pregnant? No. of C-sections Largest Baby? Any pregnancy complications?_ Past Gynecological History o Pelvic tumors/fibroids o Unusual vaginal discharge o No periods o Vulvar problems o Pelvic infections (PID) o Birth control use o Painful periods o Vaginal problems o Pelvic surgery Type o Abnormal bleeding o Genital warts o Abnormal Pap o Endometriosis Describe o Other Result o Herpes o Pelvic prolapse o Vaginal Infections o Infertility o Menopause First date of last period Was it normal? o Yes o No Periods started at age Occur every Duration Do you perform monthly self-breast exams? o Yes o No Have you had sexual intercourse? o Yes o No If yes, o Vaginal o Anal o Oral o Men o Woman Age of onset of intercourse Number of lifetime partners Number of partners in last 2 years Condom protection always? o Yes o No Unprotected intercourse (no condom) since last period? o Yes o No Any missed birth control pills since last period? o Yes o No How do you protect from HIV/AIDS/STDs/Hepatitis B and C? 6

7 Past Medical History Please check all that apply. o Alcoholism o Cancer o Heart murmur o Osteopenia o Allergies Type o Hemorrhoids o Osteoporosis o Anemia o Circulation problems o Hepatitis C o Prior blood transfusion o Angina (chest pain) o COPD o High blood pressure Reason o Anxiety o Crohn s disease o High cholesterol o Seizure disorder o Arthritis o CVA (stroke) o Irritable bowel disease o Severe mood changes o Asthma o Depression o Kidney disease/stones o Thyroid disorder o Atrial fibrillation o Diabetes o Liver disease o Ulcers o Bipolar disrder o Eating disorder o Mental illness o Urinary incontinence o Breast pain o Gallbladder disease o Migraine headaches o Urinary tract infections o Blood clots o Heart failure o Obesity o Valve disease o Blurred Vision o Heartburn o Osteoarthritis o Vericose veins Past Surgical History Please list all prior surgeries. Include dates and any complications Immunizations Please list the last date of the below immunizations. Approximate dates are fine. Date of last flu shot? / / o None Date of last pneumonia shot: / / o None Date of last tetanus shot: / / o None Date of last shingles shot: / / o None 7

8 Medications List any prescription, herbal or over-the-counter medications that you are currently taking. Medication name Strength Dosage/Directions Example: Aspirin 325mg 1 tab daily Please list your preferred pharmacy name and address: Do you have allergies to medications? o Yes o No If yes, please list drug(s) and reactions(s): 8

9 Family History Please indicate if your mother, father or sibling has any of the following diseases now or if it was their cause of death (COD). Please also indicate if aunt/uncle/grandparents in the other box. Check all that apply. Diabetes Heart disease High blood pressure High cholesterol CVA (stroke) Kidney disease Alcoholism Alzheimer s disease Asthma Blood clots Cancer * Circulation problems Depression/anxiety Development delays Eczema Irritable bowel disease Mental illness Migraines Obesity Seizure disorder Substance abuse Other family history MOTHER FATHER SISTER(S) BROTHER(S) OTHER Yes COD Yes COD Yes COD Yes COD Yes COD Relationship * If you have a family history of cancer, please indicate which type(s): 9

10 Social History Check all that apply. Do you have good family support? o Yes o No Do you feel safe at home? o Yes o No Any religious or cultural needs that you would like our medical practice to know? o Yes o No If yes, please describe: Tobacco Use History Uses tobacco: o Currently o Never o Formerly Tobacco type: o Cigarettes o Chewing o Cigar o Pipe o Snuff o Other Amount per day: (packs, ounces, cigars, pipes) Number of years: Tobacco cessation ever discussed: o Yes o No Secondary smoke exposure: o Yes o No Alcohol Use History Drinks alcohol: o Daily o Weekly o Monthly o Occasionally o Rarely o Never Type: Caffeine Use History Drinks Caffeine: o Coffee o Pop o Tea o Energy Drinks How many daily: Illegal Drug Use History Uses illegal drugs: o Currently o Never o Formerly If currently or formerly please indicate drugs used: Have you ever sought treatment for drug use: o Yes o No Exercise History Type of exercise you prefer: o Cycling o Jogging/Running o Tennis o Weights o Golf o Swimming o Walking o Yoga o Other: Exercise frequency: o Daily o 2-3 times a week o 3-4 times a week o Occasionally 10

11 AUTHORIZATION TO DISCUSS PERSONAL HEALTH INFORMATION WITH FAMILY AND FRIENDS Date: Name Relationship Phone Specific Visit, Restrictions: Date to Patient Procedure or Visit, Procedure Revoked Diagnosis Diagnosis You have my permission to discuss my personal health information with the individuals designated above. This authorization will be effective on the date below and will remain in effect until revised or revoked. This authorization can be revoked at any time, either verbally or in writing. Patient Signature Patient Representative Signature Date Reviewed and/or Revised Date Signature Date Signature Date Signature 11