Directions to Whole Woman Health - located in the NW Des Moines/Beaverdale area:

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1 Whole Woman Health Patient Registration Form Welcome New Patient! We are pleased you have chosen Whole Woman Health. Below is your registration form as well as Medical History and Assessment forms. Please take the time to read and complete all information as it will aid in your care. Bring this packet with you to your initial appointment along with any lab reports performed within the last six months that would pertain to your visit with us. At this time we are accepting Wellmark Blue Cross/Blue Shield insurance and United Healthcare. Payment is due at the time of your appointment if you do not have coverage with the above plans. We do not accept Medicare or Medicaid, and therefore you cannot file with either of these. Whole Woman Health makes every attempt to provide the quality medical care you expect and deserve. If you have any questions or concerns, please contact our office at Patients are seen by appointment only and we recommend you schedule as far in advance as possible. If you must cancel an appointment, we ask that you contact us at least 48 hours in advance. Please notify us if you will need accommodations for a disability. Also, due to our sensitivity to perfumes, we ask that you refrain from wearing fragrances at the time of your visit. We appreciate your consideration. Our regular office hours are Monday, Wednesday and Thursday 9:00am - 5:00pm, and Friday 9:00am - 3:00pm. We are closed for lunch from 12-1:00. Our office is closed on Tuesdays, but evening appointments may be arranged for special circumstance. Directions to Whole Woman Health - located in the NW Des Moines/Beaverdale area: From I-235: 1. Coming from the East, take the 42 nd St Exit (Exit 5B) and turn right 2. Coming from the West, take the 42 nd St Exit (Exit 5B) and turn left 3. Travel north on 42 nd until you come to a T intersection (past University Ave) 4. Turn left onto Forest Ave 5. Travel 3 blocks to 4507 Forest (we are on the corner of Forest & 45 th, Peterson Painting sign on side of building). From I-80: 1. Take the Merle Hay Rd Exit 2. Travel South on Merle Hay Rd to Hickman Rd, turn left 3. Take Hickman Rd to 48 th St, turn right 4. Take 48 th St to Forest Ave, turn left 5. Travel 3 blocks to 4507 Forest Ave (we are on the corner of Forest & 45 th )

2 Whole Woman Health Patient Registration Form Date Patient Name Last First Middle Initial Address Street Apt/Unit# City State Zipcode Birthdate Age Marital Status Sex address Place of Employment Phone Numbers Home Cell Work *May we leave messages? If so, on which phones? Home Cell Work Do you have an address where we may contact you? How did you hear about our office? Emergency Notification: Name Phone Relationship to you Primary Insurance *Secondary Insurance Primary Holder Self Spouse Parent/Guardian Name Birthdate (if Other Than Self) Do you have a durable power of attorney for health care decisions? Yes No Consent to Treat: I hereby authorize the health care provider of Whole Woman Health to administer such treatment as they deem necessary. I realize that students may be involved in my care. I also certify that no guarantee or assurance has been made as to the results that may be obtained from the treatment. Financial Responsibility: I agree that I am financially responsible or all charges for services rendered. I agree to pay all charges which are not covered by insurance or which are not promptly paid my the insurer. I understand and agree that it is my responsibility to obtain prior authorization required by my insurance company and to take all other steps to qualify for insurance coverage. Release of Information: Please refer to the Notice of Privacy Practices and Consent to Release Information. Patient s Signature Date Parent/Guardian Signature Dat

3 Medical History Form Date completed Name Date of Birth Date of last Physical Exam and Pap Smear History of Abnormal Results Date of last Mammogram Bone Density Test Blood Lipids Colonoscopy What are your immediate concerns today? HEALTH HISTORY: Place a if you have had any of the following. Immediate family =parents, brothers, sisters. You Family Condition You Family Condition You Family Condition heart diabetes headaches anemia bowel problems uterine problems stroke Mental illness breast problems vascular problems gallbladder abnormal pap smear high cholesterol eye problems ovarian problems high blood pressure cancer pelvic infections other blood problems depression allergies thyroid problems dizziness/numbness herpes dermatology/skin joint/bone neurological problems seizures liver disease osteoporosis surgery eating disorder fractures lung problems arthritis kidney/uti other autoimmune disease Please explain above answers: Hospitalizations: MENSTRUATION/REPRODUCTIVE HISTORY: First day of last menses Number of days of bleeding Number of days from first day of menses to first day of next menses Age of first period Heavy, painful or irregular menses? Pregnancies(#) Births(#) Miscarriages (#) Abortions(#) Vaginal deliveries(#) Cesarean deliveries(#) Complications Age of onset of menopause

4 Name: Date of Birth LIST CURRENT: MEDICATIONS SUPPLEMENTS HERBS LIFESTYLE Do you smoke? If so, how many cigarettes/cigars a week Do you consume alcoholic beverages? If so, how many a week Any recreational drug use? If so, how frequently? Describe your exercise in a typical week Spiritual Practices Counseling, chiropractic, acupuncture, or other healthcare providers Please describe 2 days typical food intake. Include water, alcohol and other beverages: Day 1 Breakfast Lunch Dinner Snacks Day 2 Breakfast Lunch Dinner Snacks Whole Woman Health Name: 4507 Forest Ave Date of Birth Des Moines, IA 50311

5 Patient Assessment Hormone Symptoms Female Estrogen Deficiency Estrogen Dominance/Progesterone Deficiency Progesterone Excess Hot flashes Mood swings (PMS) Hot flashes Sleepiness Night sweats Tender breasts Night sweats Mild depression Vaginal dryness Water retention Vaginal dryness Breast tenderness Foggy thinking Nervous Foggy thinking Candida Memory lapses Irritable Memory lapses Incontinence Anxious Incontinence Tearful Fibrocystic breasts Tearful Depressed Uterine fibroids Depressed Sleep disturbances Weight gain hips Sleep disturbances Heart palpitations Bleeding changes Heart palpitations Bone loss Headaches Bone loss Headaches Cold body temperature Headaches Androgen Excess Androgen Deficiency Increased facial hair Low libido Sleep disturbances Increased body hair Vaginal dryness Bone loss Loss of scalp hair Fatigue Decreased muscle mass Acne Aches/pains Heart palpitations Oily skin Memory lapses Fibromyalgia Nervous Foggy thinking Irritable Irritable Incontinence Thinning skin Anxious Depressed Ovarian cysts Elevated triglycerides Sleep disturbances Breast cancer Cortisol Excess Cortisol Deficiency Sleep disturbances Heart palpitations Fatigue Bone loss Headaches Sugar craving Fatigue Stress Allergies Weight gain waist Cold body temperature Chemical sensitivity Loss of muscle mass Sugar cravings Stress Thinning skin Low libido Cold body temperature Elevated triglycerides Hair loss Irritable Breast cancer Increased facial hair Arthritis Irritable Increased body hair Heart palpitations Anxious Acne Aches/pains Memory lapses Nervous Depressed

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