PATIENT REGISTRATION

Transcription

1 3160 ALZANTE CIRCLE MELBOURNE, FL HOPE PATIENT REGISTRATION DATA BASE Name: Address: Marital Status: M S W D D.O.B.: Soc. Sec.#: Occupation: Employer: Who referred you to this practice? Address: Phone#: ( ) Date: Tel: (H)_ (W)_ (C)_ Spouse/Partner Name: D.O.B.: Soc. Sec.#: Occupation: Employer: Primary Care Physician: Who would you like us to contact in case of emergency? Relationship: Phone#: ( ) INSURANCE INFORMATION PRIMARY INSURANCE:_ Member Name: Claims Address: City/State/Zip: SECONDARY INSURANCE: Member Name: Claims Address: City/State/Zip: Group/Policy#: Member #: Phone#: ( ) Group/Policy#: Member #: Phone#: ( ) CONSENT All services will require payment at the time services are provided. I agree that all charges that are not directly paid by the insurance company will be my responsibility. I authorize payment of benefits, as determined by the company, directly to physician. Patient Signature Date

2 Patient Name: Date: MEDICAL HISTORY PATIENT MEDICAL HISTORY (1 of 4) Age: Are you Married / Single / Divorced? Number of Years Married / Current Relationship: Are you Trying to Conceive? How Long Have you now Been Trying to Conceive? Months/Years When was the Last Time you Used Contraception? What Kind of Contraception did you use Last? Reason for Visit: HISTORY OF FERTILITY THERAPY Have you Been Treated for Infertility Before? If yes, Where did you Undergo Treatment? Who was Your Physician? Who is Your Referring Physician? What is the Reason for your Infertility? What Testing or Treatment have you had for the Current Problem? Check all That Apply and the Results if Known: Semen Analysis Basal Body Temperature LH Testing Postcoital Test Blood Tests Endometrial Biopsy Hysterosalpingogram (HSG) Hysterosonogram Ultrasound Antibody Testing Laparoscopy Hysteroscopy Laparotomy Chlamydia Cultures/Titer Other - Specify What Medications / Treatment Have you Taken for Infertility? Medications Month/Year Number of Cycles Insemination IUI Outcome Delivery Clomid Letrozole Metformin Follistim, Gonal F, Bravelle Menopur Parlodel / Dostinex Steroids Danazol Did you Undergo IVF in the Past? Lupron Estrogens/Progesterones Date Location Protocol Response # of Eggs Retrieved ICSI Y/N # of Eggs Fertilized Complications Other-Specify None # of Embryos Transferred Frozen Embryos Outcome/ Complications

3 Patient Name: Date: PAST MEDICAL HISTORY PATIENT MEDICAL HISTORY (2 of 4) Have you ever had any Surgery? If yes, Please Specify: Do you Have Medical Conditions? If yes, Please Specify: Do you Have Psychiatric Conditions? If yes, Please Specify: Please List Current Medications? Please List any Drug Allergies? If yes, Please Specify: GENERAL / ENDOCRINE HISTORY Do you or Have you ever had (Check all That Apply): Cardiovascular Problems High Blood Pressure Heart Disease Mitral Valve Prolapse Respiratory Problems Gastrointestinal Problems Liver Problems Urinary Problems Neurologic Problems Musculoskeletal Problems Breast Problems Breast Discharge Mammogram Lymphatic Problems Blood Problems Anemia Blood Transfusions Skin Problems Skin Cancer Eating Disorder Hormonal Problems Diabetes Thyroid PCOS Excess Hair Growth DES Exposure Cancer: Specify Gonorrhea Chlamydia Pelvic Infection PID Herpes Syphilis Genital Warts Yeast Infections Abnormal Pap Smears Ovarian Cysts Fibroids Endometriosis Abnormal Bleed D&C IUD Have you Ever had Surgery for Endometriosis? Have you Ever had Surgery for Fibroid? Have you Ever had Surgery on Your Fallopian Tubes? Have you Ever had Surgery for Lysis of Adhesions? Have you Ever had Cervical Conization or Cautery? _ MENSTRUAL HISTORY Age at First Period?_ Last Annual Exam/Pap Smear Are your Periods Regular? Last Menstrual Period If yes, What is the Usual Number of Days Between Periods? If no, how Often do you Normally Menstruate? How Many Times per year do you Menstruate? What is the Usual Duration of Your Period? Use: Tampons Pads Is your Bleeding Normal? If no, Please Specify: Are Your Cramps: Mild Moderate Severe None Do you Have to Take Pain Medication for Cramps? If yes, Specify Medication: Do you Bleed or Spot Between Periods? Can you Tell When Your Period is About to Begin? If yes, Please List any Premenstrual Symptoms: Do you Suffer From Pelvic Pain? If yes, When do you Suffer From Pelvic Pain? What Treatments if any Have you Received and When?

4 Patient Name: Date: PERSONAL HISTORY PATIENT MEDICAL HISTORY (3 of 4) Occupation: Do you Exercise? Type? Hours / Day / Week: Do you Follow a Particular Food Diet? Have you Lost or Gained Greater Than 20 Pounds in the Last Year? Do you Have a History of Depression, Panic Attacks, Anxiety Disorder or any Other Psychiatric Problems? If yes, Which? Hospitalized? Treatment: Do you use or Have you Ever Used (Check all That Apply): Alcohol: If yes, are you a Social Drinker? # Drink / Day / Week: Cigarettes: Number of Packs per day: When did you Quit? Recreational Drugs: Type? When? How Much? MARITAL HISTORY Have you Ever Been Married? # of Times: How Many Times per Week do you and Your Partner Have Sexual Relations? Is Intercourse Painful or Difficult for you? Do you use Lubricants for Intercourse? If yes, why? If yes, Which one? If yes, how Often? Do you Douche Before or After Intercourse? What Form of Contraception do you use now or Have you Used in the Past? None Pills IUD Diaphragm Depot Shot Nuva Ring/Patches Condom Rhythm/Withdrawal PREGNANCY HISTORY Have you Ever Been Pregnant? Total Number of Pregnancies: Miscarriages Abortions Ectopics_ Did you Ever Require Infertility Therapy to Conceive? 1st 2nd 3rd 4th 5th Date/Year Current Partner How Long to Conceive Treatments to Conceive _ Type of Delivery and # of Weeks Sex & Weight of Baby Complications Please Explain any or all Complications During or After Your Pregnancies? FAMILY HISTORY What is Your Ethnic Background? Self Husband/Partner Are Your Parents Healthy? Mother Father Do you Have any Brothers? Sisters? Is There a Family History of Significant Disease? Infertility/Recurrent Pregnancy Losses: Mental Retardation/Tested for Fragile X: Birth Defects: Neural Tube Defects: Inherited Diseases or Chromosomal Disorder: Cystic Fibrosis (Northern European) Sickle Cell Anemia (African) Thalassemia α / β (Mediterranean / Asian) Tay-sachs, Canavan, Familial Disautonomia, Gaucher s, Niemann-Pick (Ashkenazi) Heart Disease/Congenital Heart Defects: Breast/Ovarian Disease: Diabetes/Thyroid Problems: Other:

5 Patient Name: Date: PARTNERS HISTORY PATIENT MEDICAL HISTORY (4 of 4) Name: Age:_ Occupation:_ Does Your Husband / Partner use any of the Following: Tobacco Alcohol Illicit Drugs Steroids Other Medications Occupational/Recreational Hazards: Cycling / Hot Tubs? Any Family History of Infertility or Unexplained Pregnancy Losses: Medical Problems: Sexual Difficulties or Dysfunction: Previous Surgeries: Any History of Hernia Surgery, Undescended Testis: Previous Trauma / Chemotherapy / Radiotherapy: Previous Sexually Transmitted Diseases / Systemic or Febrile Illnesses / Orchitis or Mumps Orchitis: Previous Marriages: How many? #of Children:_ Ages:_ Previous Semen Analysis: How Many? When / Where: Outcome: Previous Urologic Evaluation: When / Where: Outcome:

6 Patient Name: Date: Consent to the Use of Disclosure of Health Information for Treatment, Payment, or Healthcare Operations I,, understand that as part of my healthcare, this practice originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as: A basis for planning my care and treatment A means of communication among the many health professionals who contribute to my care A source of information for applying my diagnosis and surgical information to my bill A means by which a third-party payer can verify that services billed were actually provided, and A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the right to review the notice prior to signing this consent. I understand that the organization reserves the right to change its notice and practices and, prior to implementation, and will mail a copy of any revised notice to the address I ve provided. I understand that I have the right to object to the use of my health information for directory purposed. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already take action in reliance thereon. In addition to disclosures necessary for my care and treatment and payment for services I give authorization to you to disclose my health information to the following individuals: I fully understand and accept / decline the terms of this consent. _ Signature Date

7 Patient Name: Date: PLEASE PRINT CLEARLY Authorization for Release of Protected Health Information (COPY OF RECORDS TAKES 7 TO 14 BUSINESS DAYS TO PROCESS) Full Name: SSN: Birthdate: Address: City: State: Zip: Phone (Home): (Cell): (Work): I, the undersigned, authorize and request Viera Fertility Center to copy the following information from my medical record(s) for care and/or treatment that I received from the dates of service: ( to ). _ General Care and Treatment _ All Pap Smears/Cultures _ All Ultrasounds _ All Lab and/or X-ray Results _ All Diagnostic and Operative Records Specific Records Only: Please Check One: Release to: Obtain from: Name and/or Organization: Address: City: State: Zip: Phone:_ Fax: Please Check One: Mail Pickup Fax: Attention: The protected Health Information may be used or disclosed for the following purposes: Healthcare Insurance Legal Personal Other Please do not release the following: Medical records are to include any and all Federal and State protected information without limitation to include diagnosis, treatment, and/or examination related to mental health related care, drug and/or alcohol abuse, HIV testing/aids, and sexually transmitted diseases. I understand that the release of these records may not condition treatment, payment, enrollment, benefits based upon my authorization and that individually-identifiable health information disclosed may no longer be protected by Federal laws or regulation and may be subject to re-disclosure by the recipient. I understand I have a right to inspect and obtain a copy of any information disclosed. I hereby release Viera Fertility Center and its employees from any and all liability that may arise from the release of information as I have directed. I understand that the state law prohibits the re-disclosure of the information disclosed to the persons/entities listed above without my further authorization. I understand that if requesting records for personal purposes or transfer of care to another provider, I may be charged a fee of $1.00 per page up to the first 25 pages and then $0.25 for every page thereafter. This fee must be paid in advance or upon release of records. Signature of Patient:_ Date: Witness: Date: This authorization may be revoked at any time by written request. This authorization will expire one year from the date of this authorization.