Welcome to OBGYN Associates.
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- Sherman Small
- 6 years ago
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1 Welcome to OBGYN Associates. We are happy you have chosen our practice for your specific medical needs. Please fill out the enclosed forms and bring them with you to your appointment. We do ask that you please arrive at our office at least twenty minutes before your scheduled appointment time, this enables us to complete our registration process. The charge for your initial appointment will be approximately $237 to $316, any additional services will be charged accordingly. Fees are to be paid at the time of service. We accept cash, personal check, Visa, MasterCard and Discover for payment. If you have one of the following insurance carriers we will file this charge with your insurance company on your behalf. If you do not have your current insurance card with you at your appointment you will need to pay at the time of service and file for reimbursement. Advantage HMO Community Health Alliance Sagamore Cigna PPO Medicare United HealthCare Blue Cross/Blue Shield/Anthem Aetna PPO Select Health Network Private HealthCare Systems (PHCS) Indiana Medicaid MHS, Anthem or MDWise SHN WE DO NOT ACCEPT MICHIGAN MEDICAID Many insurance companies are now requiring their members to use a preferred laboratory. Please inform us if you need to use a lab other than the South Bend Medical Foundation. If you need a referral from your primary care physician, it is your responsibility to obtain the referral prior to your appointment. If you are unsure if you need a referral or if you have any questions regarding your benefits, please contact your insurance company. Thank you. am Just a reminder that your appointment is scheduled for / : pm Please bring a list of your current medications including strengths and dosages.
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4 Please complete both sides of form University Commons, Ste 310 South Bend, IN OB-GYN ASSOCIATES OF NORTHERN INDIANA, P.C. NAME: AGE: DATE: INITIAL PATIENT SELF-HISTORY FORM Provide all information requested to the best of your ability. ALLERGIES (Include medications, Latex, Iodine) GYNECOLOGIC HISTORY Age at first menses (period) Age at menopause (if applicable) (The following questions refer to your natural periods when not on birth control pills or hormones) Usual # of days of period Period interval (1 st day to 1 st day) days How many days are: Heavy Medium Light Have you ever had an abnormal pap smear? If yes, how was it treated? When? Date of last pap smear Have you had a mammogram? When? Result Types of birth control used, including vasectomy Have you had any gynecologic surgery? (Including Tubal Ligations, D&C s, Cryo, Leep, Ovarian surgery) If yes, what kind? When? Do you have any knowledge of your mother using hormones (DES, Diethylstilbestrol) during her pregnancy with you? PREGNANCY HISTORY # of full-term deliveries # of premature deliveries # of miscarriages Was surgery needed? # of abortions Any complications? Any tubal pregnancies? When? # of vaginal deliveries # of Cesarean sections Years of deliveries Any serious complications during your pregnancies or deliveries? RISK FACTORS Your answers to these questions help us to determine if you have risk factors for cancer, infections or AIDS: Have you ever received a blood transfusion? Do you smoke? How much? How many years? Do you consume alcohol? How often? Have you ever used marijuana, cocaine, heroin, barbituates, or speed? If yes, last used? Any needles? Age at first intercourse Total # of sexual partners Total # of sexual partners in last year Have you had any sexually transmitted infections? If yes, what? When? Do you believe yourself to be at risk of exposure to the AIDS virus? Please complete both sides of form.
5 SURGERY (Other than gynecologic) TYPE WHEN DOCTOR COMPLICATIONS HOSPITALIZATIONS (Non-surgical, other than pregnancy) CONDITION WHEN DOCTOR TREATMENT PAST AND PRESENT MEDICAL PROBLEMS Other Medical/Surgery History not listed FAMILY HISTORY Include Mother (M), Father (F), Sister (S), Brother (B), Grandmother (GM), Grandfather (GF), and Children (C) only. Diagnosis Family member Indicated by M-Mother, F-Father, B-Brother, C-Child, etc. Other Family History not listed Check if adopted/family history not known
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