REGISTRATION / UPDATE

Transcription

1 Obstetrics & Gynecology Marietta M. Tan, M.D. Wendy Crenshaw, M.D. Dana Edwards, M.D. Tillaikarasi Kannappan, M.D. Jigisha Upadhyaya, M.D. Gregory R. Klis, M.D. James Tsai, M.D. Noel DelMundo, M.D. Jacqueline Olango, M.D. Luis Lopez, M.D. Sonia Ghai, M.D. Physician Assistants Kasey Swafford, PA-C Rosa Luna, PA-C Nurse Practitioners Kathleen Griffin, FNP-C Anne Graham, FNP-C Patient Information REGISTRATION / UPDATE Date: Doctor: Primary Care Doctor: Full Name: Mailing Address: Previous Name Used: Home Phone: City/State: Zip: Alternate Phone#: Race: Religion: Marital Status: S M D W Birthdate: Age: Soc. Sec. #: Driver Lic #: If Minor: (Ask for Disclosure Information) Parent / Guardian Name: Date of Birth: Employer Information Employer: Occupation: Phone: Address: Hours can be reached: If we have to contact you by phone, how shall we identify ourselves: SDMG Dr s Office Other Best phone number to reach you: Spouse Name: Date of Birth: Soc. Sec#: Spouse Employer: Work #: Occupation: Phone #: Alternative #: Cell #: Insurance Information Primary Ins.: Group/Plan#: Policy / ID# Ins. Address: Policyholder s Full Name: Eff. Date: DOB: Secondary Ins.: Group/Plan#: Policy / ID# Ins. Address: Policyholder s Full Name: Contact Info In Case of Emergency, Call: Eff. Date: Phone #: Alternative #: DOB: Relationship: Financial Agreement & Release of Information I agree to pay all fees and charges for treatment rendered on behalf of myself and members of my family shown by statements, promptly upon presentment thereof, unless credit arrangements are agreed upon in writing. I understand that co-payments and deductibles, which have not been satisfied, are my responsibility and are required at the time of the visit, and if I am unprepared to pay, my visit will be reappointed. I also understand that I will be charged and billed for any appointment not kept without a minimum of twenty-four hours prior notification to the office. I fully understand that if services are provided to me and/or members of my family, which are deemed to be not covered by my health plan, that I am responsible for payment in full for those services. My signature, below, constitutes agreement to the aforementioned and agreement to pay for such services. Charges shown by statement are agreed to be correct and reasonable unless protested in writing within thirty days of billing date. If it is necessary to assign my account to a collection agency and/or attorney to collect and unpaid balance for services previously rendered to myself or my family member, I agree to pay for all collection agency and all attorney fees and costs. 100 Old River Road Bakersfield, California (661) Phone (661) Fax The above information is for the purposed of obtaining credit and is warranted to be true. I authorize San Dimas Medical Group, Inc., to verify employment, insurance eligibility and benefits. I authorize assignment of my insurance payment to San Dimas Medical Group, Inc. and hereby authorize my Physician to release any information acquired in the course of my examination or treatment to my insurance company as needed. Signature of Patient or Legal Representative Date Revised 1/24/2014

2 GYN History Date: Chart #: Patient Name: Date of Birth: Address: Primary Language: City/State/Zip: Telephone Number: Obstetrics & Gynecology Marietta M. Tan, M.D. Wendy Crenshaw, M.D. Dana Edwards, M.D. Tillaikarasi Kannappan, M.D. Jigisha Upadhyaya, M.D. Gregory R. Klis, M.D. James Tsai, M.D. Noel DelMundo, M.D. Jacqueline Williams-Olango, M.D. Luis Lopez, M.D. Sonia Ghai, M.D. Physician Assistants Kasey Swafford, PA-C Rosa Luna, PA-C Nurse Practitioners Kathleen Griffin, FNP-C Anne Graham, FNP-C What are you being seen for today: How many pregnancies have you had? Any miscarriages Yes No If yes, how many? What year(s)? Any elective abortions? Yes No If yes, how many? What year(s)? Any ectopic (tubal) pregnancies? Yes No If yes, how many? What year(s)? Any still births? Yes No If yes, how many? What year(s)? Please list the cause of still birth(s), if known: Any children born with birth defects? Yes No If yes, how many? What year(s)? If yes, please specify: What was the first day of your last period? How old where you when your period started? How often do you have periods? How many days do your periods last? Do you have cramping during your period? Yes No Your periods are (please circle) Heavy Light Regular Do you have premenstrual symptoms? Bloating Swelling Headaches Breast Tenderness Please specify any other symptoms you may have: Do you have spotting in between periods? Yes No What are you using for birth control (please circle all that apply) Abstinence Condoms Foam IUD Paragard Tubal Coils Barrier Contraceptive Patch Hysterectomy Natural Family Planning Vaginal Ring Bilateral Tubal Depo Provera Nexplanon Rhythm Vasectomy Birth Control Pills Diaphragm IUD Mirena IUD Skyla Withdrawal If you are taking birth control pills, what is the brand name? How long have you been taking birth control pills? Have you had any problems with them? Yes No If yes, please explain: 100 Old River Road Bakersfield, California (661) Phone (661) Fax When was your last pap smear? Results were: Normal Abnormal When was your last mammogram? Results were: Normal Abnormal Do you perform self-breast exams? Yes No When was your last colonoscopy? Results were: Normal Abnormal When was your last bone scan? Results were: Normal Abnormal Preferred Pharmacy and Location: Primary Care Physician: Insurance Coverage: Revised: Page 1 of 4

3 Do you have vaginal discharge? Yes No If yes, is the color Grey Brown Yellow Other: Is the discharge (please circle) Heavy Light Normal Is the discharge (please circle) Watery Thick Normal Cheesy White Bloody Do you have bleeding after intercourse? Yes No Is intercourse painful? Yes No If yes, please explain? Are you allergic to any medications? Yes No If yes, please list the medications and your reaction: Medication Reaction Are you currently taking any medications? Yes No If yes, please list the medications and their dosage: Medication Dose Treatment for Pregnancy History Day / Month / Year Was Pregnancy Miscarriage Elective Abortion Was Delivery (please list gestation wks) Full Term Pre Term Delivering Physician Delivery Vaginal or C-Section Sex of Child Birth Weight **Complications ** If you noted Yes to Complications, please specify year and type of event (i.e., miscarriage, ectopic, elective abortion) Medical History Please list any medical conditions you have been or are currently being treated for: Revised: Page 2 of 4

4 Genetic History Certain genetic diseases are common in some ethnic groups. Please help us to determine your risk factors. Are you or your partner of African American Ancestry? Yes No If yes, have either of you been tested for Sickle Cell trait (Sickle Cell Anemia carrier?) Yes No Are you or your partner of Easter European Jewish decent? Yes No Ashkenazi? Yes No If yes, have either of you been tested to see if you are a Tay-Sachs carrier? Yes No Are you or your partner of Asian Mediterranean (Greek, Italian, etc.) decent? Yes No Are you or your partner adopted? Yes No If yes, is there a family history available? Yes No Have you or your partner been exposed to blood and body fluids of individuals with: HIV, Hepatitis C, or Hepatitis B? Yes No Past Surgical History Please list any and all of your surgeries: Year Type of Surgery Reason for Surgery Social History Do you currently use illicit drugs? Yes No If yes, please list: Do you have a history of drug abuse? Yes No If yes, please list: Do you drink? Yes No If yes, how often? How many per day? Are you currently sexually active? Yes No What is your marital status? Single Married Living with Partner Separated Divorced What is your ethnicity? (please circle) African American Hispanic Asian / Filipino American Indian (or Alaskan Native) Native Hawaiian / Pacific Islander Unknown Other: What is your occupation? In your occupation, are you potentially exposed to infectious diseases or hazardous materials? Yes No If yes, please list all materials you are potentially exposed to: (i.e. radiation, biohazards, chemicals) Do you smoke? Yes No If yes, how many per day? Do you use caffeine? Yes No Do you exercise? Yes No If yes, do you exercise (please circle) Daily Weekly Seldom Revised: Page 3 of 4

5 Family History Please list family members medical conditions (please include parents and siblings) **Do NOT include in-laws or adopted parents or siblings. **Be sure to list any immediate family members with any history of breast, cervical, ovarian, uterine, or colon cancer. Relative Type (Father, Mother, Living / Deceased If deceased, age at death Illnesses / Disorders Siblings) Date of last Immunization or vaccine: Tdap: Gardasil: Influenza (flu): Other: Revised: Page 4 of 4