PATIENT REGISTRATION FORM (ecw)

Transcription

1 PATIENT INFORMATION 4392 THE COLORADO CENTER FOR GYNECOLOGIC ONCOLOGY PATIENT REGISTRATION FORM (ecw) (Please print) Patient s Legal Name: (Last) (First) (MI) Preferred Full Name (if different from above): Date of Birth: Address: City, State, Zip: Home Phone Number (landline): Cell: Work: Marital Status: [M] [S] [D] [W] Address: Employer Name: Pharmacy Name: Address: Pharmacy Phone#: Gender Identity: Female Male Transgender Female to Male Transgender Male to Female Genderqueer Choose not to disclose Additional Gender category not listed Race: American Indian/Alaska Native Asian Native Hawaiian/Pacific Islander Black/African American White Hispanic Chose not to disclose Other not listed Ethnicity: Hispanic or Latino Not Hispanic or Latino Choose not to disclose Preferred Language: English Spanish ASL Japanese Mandarin Korean French Indian: Hindi, Tamil, Gujarati etc Swahili Russian Arabic Vietnamese Haitian Creole Bosnian/Croatian/Serbian/Serbo-Croatian Albanian Burmese Tagalog Farsi-Iranian/Persian Portuguese Cambodian Other not listed Patient Social Security Number: - - Primary Care Physician Referring Physician RESPONSIBLE PARTY INFORMATION (If not self) (Information used for patient balance statements) Responsible party: Another patient Guarantor Self Check here if address and telephone information is same as patient Responsible party name: (Last) (First) (MI) Date of birth: MM /DD /YYYY Sex: Female Male Responsible Party Social Security Number: - - Phone number: Address: City, State: ZIP: INSURANCE INFORMATION: Provide your insurance card(s) (primary, secondary, etc.) to the front desk at check-in. EMERGENCY CONTACT INFORMATION Emergency contact name: (Last) (First) Phone number: Do you have a living will? Yes No Emergency contact relationship to patient: Address City, State: ZIP: Home phone: Work hone: Ext. Guardian GENERAL CONSENT FOR CARE AND TREATMENT CONSENT TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s). This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services. You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions. I voluntarily request a physician, and/or mid-level provider (nurse practitioner, physician assistant, or clinical nurse specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s). I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents. Signature of patient or personal representative: Date: Printed name of patient or personal representative: Relationship to patient: Last Updated: May 2018

2 Last Name First Name Middle Initial Today s Date MAIN REASON FOR YOUR VISIT: cancer pelvic mass vaginal bleeding vulvar issue Fibroids abnormal PAP smear Other OBESTECTRICAL HISTORY: How many pregnancies have you had? Vaginal C-Sections Miscarriages Abortions Stillbirths GYNECOLOGIC HISTORY: Date of last menstrual period Age of first period If not menstruating, stopped at age: because of menopause uterus removed for Date of last PAP smear: Normal Abnormal Have you ever had any abnormal PAP smear? Yes No Treatment: Date of last colonoscopy: Normal Abnormal Never Date of last mammogram: Normal Abnormal Never MEDICAL PROBLEMS: Check any problem you have been diagnosed with or received treatment for: Anemia Bone Disease/Osteoporosis Seizures Heart Attack Previous Cancer Kidney failure Heart Murmur Cirrhosis Blood clot in leg or lung Congestive Heart Failure (CHF) Gallstones Bleeding disorder (von Willebrand) Angina Stomach ulcer Glaucoma High Blood Pressure Hernia Skin disease Atrial Fibrillation Irritable Bowel Syndrome Depression Asthma Colitis Anxiety Allergies/Hay Fever Chronic Diarrhea Bipolar Bronchitis Hemorrhoids Schizophrenia COPD Arthritis Dementia/Alzheimer s Diabetes Back/neck/spine problems Other Thyroid condition Migraines

3 DOCTORS: Please list doctors who are actively caring for you. Specialty Name Phone Gynecologist Primary Care SURGERY: Please list all previous surgeries Gyn/Breast Surgery (any surgery on ovary, uterus, cervix, D&C, LEEP, C-section) Orthopedic Surgery (knee, hip replacement, back or bone surgery) Other Abdominal Surgery (colon, hernia, bowel, stomach, gallbladder) Heart Surgery (valve or bypass surgery, stents, pacemaker, defibrillator) Other Surgery (eye, lung, kidney, etc.) SOCIAL HISTORY: Do you smoke? Yes No Packs per day: Number of years: When did you quit? Do you use alcohol? Yes No Amount per week? Type: Have you ever used drugs? Yes No Past Present What type? Do you exercise routinely? Yes No How often per week? What type? Marital Status: Single Married Divorced Widowed Domestic Partner Occupation: Retired Disabled due to

4 SYSTEM REVIEW: Check any of the following symptoms that you have now Constitutional Fatigue Generalized Weakness Altered Taste Symptoms: Weight loss lbs Fever Chills Night sweats Hot Flashes Pain: Current pain score Location: Medication: Infectious Disease: Frequent or Severe Infections Cardiovascular: Chest Pain Palpitations Swelling Respiratory: Shortness of breath at rest at exertion Cough Gastrointestinal: Nausea Vomiting Difficulty Swallowing Heartburn Abdominal Pain Diarrhea Constipation Blood in Stool Dark Stool Genitourinary: Pain with urination Urination during night Hesistancy Urgency Incontinence Blood in urine Gynecologic: Abnormal Vaginal Bleeding Vaginal Dryness Vaginal Discharge Pelvic Pain Painful intercourse Bleeding after intercourse Musculoskeletal: Bone Pain Muscle Pain Joint Pain Back Pain Joint Swelling Limited range of motion Skin: Rash Itching Skin lesions Dry Skin Neurological: Headache Neuropathy Focal Weakness Paralysis Tremor Seizures Speech Impairment Dizziness Psychiatric: Nervousness Stress Depression Memory Loss Confusion Hallucinations Endocrine: Heat Intolerance Cold Intolerance Excessive Sweating Breasts: Breast Masses location Tenderness Nipple Discharge PREFERRED PHARMACY NAME: PHONE NUMBER: CITY:

5 MEDICATION AND SUPPLEMENTS: Please list all to the best of your knowledge Name of medication Dosage When do you take it? Who prescribed it? ALLERGIES: Please list all allergies to medications and materials (i.e. latex, adhesive, etc.) and the type of reaction (for example, hives, rash, swelling of throat, vomiting, etc.) Medication Reaction Printed Name Patient Signature Date

6 Authorization to Release Medical Records/Information (patient name) request Medical Records from: (patient name) authorizes medical records to be sent to: Name Address Telephone Number Fax Number (If Known) Expiration or revocation of authorization I understand that I may revoke this authorization at any time. Use of copies A copy of this authorization may be utilized with the same effectiveness as an original. Patient s name (print): Person authorized to sign for patient: (print or type) Patient s signature: Signature: Relationship to patient: Date: Date: