Lehigh Valley Physician Group
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- Bathsheba Johns
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1 Lehigh Valley Physician Group Welcome to LVPG Obstetrics and Gynecology We are pleased you have selected LVPG Obstetrics and Gynecology for your obstetrical / gynecological care. Meeting a new medical provider can cause anxiety for a patient. As such, we ask that you complete the attached forms and bring them with you to your initial visit. This will help our entire staff handle your experience more effectively. Please arrive 15 minutes prior to your appointment and be certain to bring your insurance card and co-payment, a photo ID, a list of your current medications including strength and dosage, and any required referral forms. In an effort to better serve our patients, our office has implemented an electronic medical record (EMR). This new system will make it easy for us to share information with you and members of your care team. Most importantly, this system will allow us to provide a safer, more efficient healthcare experience for you. Additionally, our office can accommodate those patients who utilize for scheduling appointments, prescription refills, or nonurgent medical questions. Please visit our website at LVHN.org/obgyn for additional information regarding our practice and providers. Thank you for giving us the opportunity to participate in your medical care. Our staff will strive to maintain your confidence in providing you with the ideal patient experience. Sincerely, The Patient Care Team of LVPG Obstetrics and Gynecology Revised:
2 LVPG Obstetrics and Gynecology PLEASE COMPLETE ALL QUESTIONS - PLEASE PRINT Today's Date Mark "X" if you are a previous patient MR# Patient Birth date Last Name First Name Middle Initial Address Street City State Zip Code Home Phone ( ) Work Phone ( ) Ext. Cell Phone ( ) Social Security # Circle: Single / Married / Divorced / Separated / Widowed / Student Spouse: Name SS# Birth date IF MINOR OR FULL TIME STUDENT Father's Name SS# Birth date Mother's Name SS# Birth date Patient's Employer (If minor or FT student, write Mother's) Company Address Occupation Spouse's Employer (If minor or FT student, write Father's) Company Address Occupation Phone ( ) Ext. Phone ( ) Ext. ALLERGIES Medication ALLERGIES - Other (Dust, pollen, pets, etc.) Family Doctor/PCP Phone ( ) 1. Primary Insurance CARD COPY. 2. Secondary Insurance CARD COPY. AUTHORIZATION: I, the undersigned patient OR parent / legal guardian of a minor patient, authorize LVPG Obstetrics and Gynecology to release any medical information necessary to process health insurance claim(s) for services rendered to me or to the minor patient. I hereby authorize direct payment by my health insurance plan(s) to LVPG Obstetrics and Gynecology for all medical services provided to me or to my dependent. (Signature of Patient or Parent / Legal Guardian) Form:
3 LVPG Obstetrics and Gynecology MEDICAL HISTORY FORM Please take a moment to complete this form to the best of your ability. You may leave questions blank for anything that you cannot answer. Thank you! Patient Name Date of Birth Date MR# PREGNANCY HISTORY: # of miscarriages # of ectopics # of abortions # of living children Year Delivery # Weeks Pregnant Vaginal C-section Vaginal C-section Vaginal C-section Vaginal C-section Baby s Gender Male Female Male Female Male Female Male Female Baby s Weight Complications PAST GYNECOLOGIC HISTORY: Age of first menses Frequency Duration Age of menopause Natural Surgical Induced by medication Sexually active: Yes No Partners: Male Female Both Age of first intercourse Number of lifetime sexual partners Current birth control method Sexually transmitted infections (e.g. chlamydia, gonorrhea, trichomoniasis, herpes, syphilis, HIV, genital warts, HPV): Abnormal Pap(s) Endometriosis Colposcopy LEEP Cone biopsy Fibroids MEDICAL HISTORY: List any significant medical problems you have now or have had in the past. High Blood Pressure Elevated Cholesterol Underactive thyroid Overactive thyroid Osteoporosis Osteopenia Migraines Blood clots (now or previous) Diabetes: Other: Controlled w/ diet Controlled w/ meds Controlled w/ Insulin PAST SURGICAL HISTORY: Hysterectomy: Abdominal Vaginal Laparoscopic Supracervical Reason: Fibroids Bleeding Prolapse Endometriosis Cancer: Type Cervical dysplasia/precancer Endometrial hyperplasia / precancer Other Ovaries removed: Left Right Both Breast Surgery: Biopsy Lumpectomy: Left Right Mastectomy: Left Right Reason: Benign Precancer Cancer Page 1 of 2
4 LVPG OBSTETRICS AND GYNECOLOGY MEDICAL HISTORY FORM Page 2 of 2 PAST SURGICAL HISTORY CONTINUED: List any other surgeries you have had. Please remember to include C-sections, tubal ligation, D&C or D&E, prolapse or incontinence surgery as well as non-gynecologic surgeries. MEDICATIONS: List any current medications, doses and instructions. (Attach a list if you are on several.) ALLERGIES: Medication / Food Reaction FAMILY HISTORY: List any medical problems that run in your family as well as the effected members. Condition Family member(s) Condition Family member(s) Breast cancer Diabetes Uterine cancer Colon cancer Ovarian cancer Other: High blood pressure Heart disease / attack Stroke Other SOCIAL HISTORY: Tobacco use: Never Quit Current: Number of packs per day Alcohol use: No Yes Average number of drinks per day Drug use: No Yes Substance VACCINATIONS: Please indicate if and when you received these vaccines: Gardasil (HPV vaccine): Date(s) Hepatitis B: Date(s) Pneumovax: Date Tetanus: Date Adacel/TDaP: Date Herpes Zoster (shingles): Date PREVENTATIVE SERVICES: Please indicate if and when you have had the following tests: Pap smear: Date Cholesterol blood work: Date Mammogram: Date DEXA scan (bone density): Date Colonoscopy: Date Sahara (bone density): Date Revised:
5 LVPG Obstetrics and Gynecology Exciting new patient videos! Emmi Programs: Interactive, online, health care education for our patients What are Emmi programs? They are a series of web-based, online, multimedia videos that educate patients and help them to take an active role in their care. How do patients receive Emmi programs? Your care provider will order an Emmi educational video that is specific to your gynecological or obstetrical care. You will receive secure s to your home address with the information you need to log into Emmi at your convenience, at any time, and view the educational programs ordered for you just like watching an online video! You can even type questions to a qualified Emmi nurse who is standing by for an interactive chat session. On the LVPG Medical Information Communication Preferences Form, please check the YES box and write your address on the line E- MAIL to receive provider-ordered online patient education programs so you can receive Emmi videos which your care provider feels are important to your care. We hope you enjoy Emmi programs, and we look forward to your feedback on the videos and to finding out if they are beneficial to you. Thank you
6 LVPG Medical Information Communication Preferences Patient MR# DOB / / As our patient, we may need to reach you when you are not in the practice. For your privacy, please indicate your preferred method for us to communicate confidential medical information, such as test or lab results, to you and/or others involved in your care. Please note that appointment reminder telephone calls may be left at the contact number(s) you list below. Please list your address to receive online health care educational programs ordered by your care provider. PLEASE INDICATE YOUR COMMUNICATION PREFERENCES BELOW: I give permission to leave medical information pertaining to me, my dependent or child, at the numbers listed below: Method Yes No Area Code, Phone #, Ext, Home telephone Answering Machine Work Phone Cell Phone for our Patient Portal secure registration to receive provider-ordered online patient education programs Pager Without specific permission, we will not release any medical information to anyone other than you. In some cases you may wish for another person to have access to your medical information. Please identify those individuals and their relationship to you (i.e. spouse, parent, son, daughter, partner etc.): Do not release medical information to anyone other than myself. I give permission to release medical information pertaining to me to the individuals listed below. Name Relationship (i.e. spouse, parent, son, daughter, etc.) Area Code, Phone # - Extension Comments I assume responsibility to inform the practice of changes in my phone number(s) or my preferences or to revoke this specific medical information authorization at any time. Signature of Patient or Patient s Legal Representative Date (Please Print Signer s Name) X:\LVPG Admin\Forms\LVPG Medical Information Communication Preferences January 19, 2013
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Last Name First Name MI SS# DOB. Address. City State Zip. Best Phone# (home/ work/ cell) Alternate # (home/ work/ cell)
39 th and Market Street, Penn Presbyterian Medical Center, MOB 340 Philadelphia, PA 19104 215-662-9775 823 South 9 th Street, 1 st Floor Philadelphia, PA 19147 267-239-2725 Last Name First Name MI SS#
Patient Health Forms
Patient Health Forms All forms MUST be completed and signed prior to seeing the Provider First: M: Last: Email Address: Home Address: Best Phone Number to Reach You: Last 4 of your social security #: Marital
NOTICE TO OUR PATIENTS
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New Patient Paperwork
Name (Last, First, M.I.): M F Email Address: Primary Phone: Race: Today's Date: DOB: Alternate Emergency Phone: Contact: American Indian/Alaska Native Asian African American Caucasian Nat Hawaiian/Pacific
Adult Health History
Patient Name Date of Birth Adult Health History This form will assist us in obtaining a complete medical history and health record on you. By completing this ahead of time it will also simply your visit
Adult Health History for New Patient
Adult Health History for New Patient Name: Birth Date: Today s Date: Preferred Pharmacy (name and location): Your answers on this form will help your health care provider get an accurate history of your
New Patient Medical History
New Patient Medical History MR #: Initial Appointment Date: / / Name: Birth Date: / / Address: City: State: Zip: Best Phone # to reach you: ( ) Second contact #: ( ) Email Address: Occupation: Marital
Breast implants Breast reduction surgery Breast biopsy Breast lumpectomy Chest reconstruction Other:
New Patient Intake Form This form lets us get to know you and know how we can help. Not every question is important to everyone, but the more you can answer, the more we can help. If there is a question
EMERGENCY CONTACT INFORMATION: Name of contact: Address: Phone#: Relationship: May we release medical information to this person?
! Page 1 of 5 PATIENT INFORMATION: NAME (Nombre): DATE OF BIRTH (Fecha de Nacimiento): ADDRESS (Direccion): CITY (Ciudad): STATE(Estado): ZIP(Codigo Postal): TELEPHONE (HOME)(# Casa): CELL(# Celular):
Welcome to About Women by Women
Welcome to About Women by Women Today s Date New Patient Questionnaire Name: Birth Date: / / Home Phone: Address: Cell Phone: Work Phone: Occupation: Employer: Marital Status: Married Living w/ Partner
Name : Date of Birth : Social Security #: Age: Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Address: May we leave a
Name : Date of Birth : Social Security #: Age: Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Email Address: May we leave a message? Home Work Cell PLEASE DO NOT LEAVE A MESSAGE Marital
We look forward to seeing you. Please feel free to call us with any questions.
1227 E. 9th Street Edmond, OK 73034 Phone: (405) 475-0100 Fax: (405) 475-9275 https://susandimickmd.com Welcome to Dr. Dimick s Office. We appreciate the opportunity to provide your health care needs.
Patient Registration Form
Patient Registration Form Date: Last Name: First: Middle: Street Address City State Zip Home Phone: Work Phone: Mobile Phone: Date of Birth: Social Security: Sex: Male Female Martial Status: Single Married
743 Jefferson Avenue Suite 203 Scranton, Pennsylvania
743 Jefferson Avenue Suite 203 Scranton, Pennsylvania 18510 570.344.9997 Name: DOB: / / Age: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Reason for your visit today: Who referred you
IN CASE OF AN EMERGENCY NOT LIVING WITH YOU
GENERAL INFORMATION Name (as it appears on insur card) Address City State Zip Home phone Cell Email Marital status DOB SS# Employer Work # Parent name (if minor) IN CASE OF AN EMERGENCY NOT LIVING WITH
Christine Chai, M.D. 901 Dover Drive, Suite 214 Newport Beach, CA 92660
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Please complete all pages of this form. Your physician will review the form with you during your appointment. Last Name: First Name: Middle Initial:
Please complete all pages of this form. Your physician will review the form with you during your appointment. Patient Information Last Name: First Name: Middle Initial: Date of Birth: / / Age: SSN: - -
New Patient Intake Form
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RESEARCH PARTICIPANT REGISTRATION FORM
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(FIRST) (MIDDLE) (LAST) STREET: CITY: STATE: ZIP CODE:
PATIENT INFORMATION EMAIL: MARITAL STATUS: [ ]MARRIED [ ]SINGLE [ ]DIVORCED [ ]WIDOWED NAME: (FIRST) (MIDDLE) (LAST) STREET: CITY: STATE: ZIP CODE: DOB: PHONE: [ ]Home [ ]Work [ ]Cell PHONE: [ ]Home [
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PATIENT REGISTRATION
PATIENT REGISTRATION "Please PRINT clearly and fill out form COMPLETELY and hand all insurance cards for copying ** First Name: Last Name: Middle Initial: Address: Apt #: City: State: Zip: Date of Birth:
Which physician are you scheduled to see? Scheduled Appointment Date: As a reminder: Please arrive minutes prior to your scheduled appointment.
Which physician are you scheduled to see? Scheduled Appointment : As a reminder: Please arrive 15-20 minutes prior to your scheduled appointment. Please bring the following on the day of your scheduled
New Patient Form Welcome!
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NEW PATIENT QUESTIONNAIRE
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PATIENT REGISTRATION (Please Print)
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FAMILY MEDICINE New Patient Medical History Form
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South Coast Medical Group Patient Registration
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NAME: DATE: DOB: REFERRD BY: REASON FOR VISIT: ROUTINE PHYSICAL PROBLEM DESCRIBE PROBLEM: AGE: CHECK IF YOU HAD ANY OF THESE MEDICAL PROBLEMS IN THE PAST MAJOR ILLNESSES YES NO YES NO Anemia Hepatitis
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Female New Patient Package
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page 1 of 6 NAME:(LAST) (FIRST) (M.I.) DATE OF BIRTH: / / SEX: M / F AGE: MARITAL STATUS: (please circle ONE) S M W D MEDICATION ALLERGIES Address (street) (city) (state) (zip) Phone numbers home: work:
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Inflammatory Bowel Disease Medical Exam Questionnaire
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Patient Information. Insurance Information
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Initial Clinical History and Physical Form
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Genetic Risk Evaluation and Testing Program
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Blue Precision HMO Annual Health Assessment Form - Adult
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ADULT INFORMATION SHEET
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COMPREHENSIVE NEW PATIENT QUESTIONNAIRE
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Welcome to PHC Family Medicine! We know you have a choice and appreciate your choosing us to provide care to your family. Dr. Frankhouser will be asking about your concerns today, but so that we can learn
Primary Care Demographic and Medical History Form
Primary Care Demographic and Medical History Form PATIENT DEMOGRAPHIC INFORMATION: Patient Name: Date of Birth: / / Street Address: City: State: Zip: Home Phone #: Work #: Cell #: Email: Preferred Method
Comprehensive Patient History Form
Comprehensive Patient History Form Date: Name: D.O.B. Past Medical History: (check all that apply) Acid Reflux Cataracts Heart disease Migraines Alcohol or Drug Problem Colitis/Crohns Heart valve problems
Directions to Whole Woman Health - located in the NW Des Moines/Beaverdale area:
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
311 North M.D. First Name. Race: Asian. White. Name. Phone: Coverage: made. Name Relationship
Robert Antonelle, M.D. White Plains Gastroenterology 311 North Street, Suite 403 White Plains, NY 10605 Patient Demographics Patient s Last Name First Name Middle Initial SSN Date of Birth Age Gender F
Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)
Patient Registration: Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA 91361 (805) 496-8522 Fax (805) 496-0469 Last Name: First Name: MI: Address: City:
Health Questionnaire
Patient Name Date of Birth Thank you for choosing Southern Cancer Center for your care. To help us best prepare for your appointment, please complete this form and bring it to your appointment. If you
Name Age DOB Sex M F Your relationship status: Single Married Life partner Widowed Address
Today s Date Contact Information Name Age DOB Sex M F Your relationship status: Single Married Life partner Widowed Address Phone numbers and E-mail (please check numbers to call or leave a message) Home
PATIENT HEALTH HISTORY
Name DOB Sex Age Date MR# PLACE CHARGE TICKET LABEL IN THE DASHED SPACE OR COMPLETE THE ABOVE: PLEASE ANSWER EACH QUESTION AS CORRECTLY AS YOU CAN BY PLACING AN "X" IN APPROPRIATE BOX What is the reason
New Patient History Form (Age 18 and over)
New Patient History Form (Age 18 and over) Obstetrics & Gynecology Name Age Date first middle last Occupation Marital Status: c Single c Married c Divorced c Widowed Referred to our office by: What is
Our office is located at 2030 Drew Street, Clearwater FL, We are on Drew Street, in between N.E Old Coachman Road and Hercules Avenue.
Dear New Patient, Thank you for choosing Dennis M. Lox, M.D to participate in your healthcare. We realize that you could have chosen any other office, so we are honored that you have chosen us. While Dr.