MOSTAFA I. ABUZEID, MD., FACOG, FRCOG

Transcription

1 Dear Patient, To facilitate your first visit we ask that you kindly forward to our office any relevant clinical records as soon as possible (if applicable), such as: - Records of previous infertility treatments Records of infertility work-up such as: semen analysis, hysterosalpingogram report and films, or CD. You will need to pick up the films (or CD) from the hospital where the test was done, and bring them to your first appointment. Recent pap smear report Previous gynecological surgeries with pathology report (e.g. laparoscopy, hysteroscopy) Any laboratory test results pertaining to hormone levels or any infertility-related reports Any pelvic ultrasound reports Please note if you have an HMO insurance (HAP, BLUE CARE NETWORK, PRIORITY HEALTH, ETC.) a referral is required. Please contact your primary care physician to get a referral prior to your visit. It is your responsibility to make sure you have your referral. If your referral is not in place, you will be given the option to reschedule or pay for your visit ($225). Please complete the enclosed forms entirely, including the insurance section. Please make sure your forms are completed and returned to us before you come in for your appointment. If we have not received the information at least 1 week prior to the appointment, the appointment will be rescheduled for a later date. You will find Medical-Release forms available on our website. We have indicated on those forms which records are needed. Please send the release form to your physician so that we can have the records before your consult. You may also call your physician to ask them to fax your records to either our Flint office at (810) or our Rochester office at (248) Currently, please forward paperwork for appointments in Dearborn or Ohio to the Rochester Hills office. The charge for the first consult ($225.00) is due in full at the time of service. We look forward to meeting you! Sincerely, MOSTAFA I. ABUZEID, MD., FACOG, FRCOG Director of Reproductive Endocrinology & Infertility, Hurley Medical Center Professor of OB/GYN, Michigan State University College of Human Medicine, Flint Campus Medical and Practice Director, IVF Michigan Rochester Hills & Flint PC

2 Date: I, want to communicate via with IVF MICHIGAN Rochester Hills & Flint PC on matters related to my health and /or my medical treatment. I understand that any Confidential Health Information that I send to the practice is not secure and is sent at my own risk. I will not hold the practice, or any of its workforce members, liable for loss of any confidentiality associated with information transmitted via . I also understand that it is not the policy of the practice to encrypt any Confidential Health Information I request to be sent to me via . Because this information is not encrypted I understand that it is not secure. I acknowledge this risk and will not hold the practice or any of its workforce members liable for any loss of confidentiality associated with such transmissions. Name: (Print Patient s Name or Name of Patient s Representative) Signature: (Signature of Patient or Patient s Representative) Witnessed by: (Print Name) Signature: (Signature of Witness) Patient declined to have information sent via (Signature of Patient or Patient s Representative)

3 IVF MICHIGAN ROCHESTER HILLS & FLINT, PC COMPASSION DEDICATION KNOWLEDGE Cancellation and Show Policy Our goal is to provide quality individualized medical care in a timely matter. shows and cancellations inconvenience those individuals who need access to medical care. We would like to remind you of our policy regarding missed appointments. Cancellation of an Appointment: In order to be respectful of the medical needs of other patients, please be courteous and call one of our offices, Flint or Rochester Hills, promptly if you are unable to show up for an appointment. This time will be reallocated to someone who is in need of treatment. If it is necessary for you to cancel your scheduled appointment, we require that you call at least 24 hours in advance. Appointments are in high demand, and your early cancellation will allow another patient access to timely medical care. How to Cancel Your Appointment To cancel your appointment, please call (248) for Rochester Hills/Dearborn/Ohio and (810) for Flint. If you do not reach the receptionist, you may leave a detailed message on our voice mail. If you would like to reschedule leave your name and phone number. We will return your call promptly. Show Policy: A no-show is someone who misses an appointment without cancelling it in adequate manner. A failure to be present at the time of a scheduled appointment will be recorded in your medical record as a no-show. First missed appointment: $25.00 fee will be billed to your account Second missed appointment: $50.00 fee will be billed to your account Third missed appointment: $75.00 fee will be billed to your account

4 IVF MICHIGAN ROCHESTER HILLS & FLINT, P.C. PATIENT INFORMATION SHEET PATIENT NAME: BIRTHDATE: SPOUSE/PARTNER S NAME: BIRTHDATE: PATIENT SOCIAL SECURITY #: SPOUSE/PARTNER SS#: ADDRESS: Street City State Zip Code CELL PHONE #: ALT. PHONE #: PREFERRED APPOINTMENT REMINDER: REFERRING PHYSICIAN: _ PREFERRED CONTACT METHOD: PATIENT EMPLOYER: SPOUSE EMPLOYER: PRIMARY CARE PHYSICIAN: PHONE #: EMERGENCY CONTACT: PHONE #: RELATION TO PATIENT: INSURANCE INFORMATION PRIMARY INSURANCE: PHONE #: NAME OF INSURED: RELATION TO PATIENT: DOB: CONTRACT #: _ GROUP #: _ SECONDARY OR SPOUSE INSURANCE: _PHONE#: (please indicate if spouse only or secondary) NAME OF INSURED: RELATION TO PATIENT: DOB: CONTRACT #: GROUP #: _ AUTHORIZATION TO RELEASE INFORMATION: I HEREBY AUTHORIZE IVF Michigan Rochester Hills & Flint PC to furnish my insurance carrier any information they may request concerning my treatment or information acquired in the course of my examination or hospitalization. SIGNED DATE AUTHORIZATION TO PAY INSURANCE BENEFITS: I HEREBY AUTHORIZE IVF Michigan Rochester Hills & Flint PC to bill my insurance company for services rendered. I understand that I am financially responsible to IVF Michigan Rochester Hills & Flint PC for any charges not covered by insurance company, and that an authorization of services is not a guarantee of benefits. SIGNED DATE ROUTINE CARE: I understand that I will continue all routine gynecologic and primary medical care, including but not limited to breast evaluation and PAP smear screening, by my primary care physician, internist or gynecologist. SIGNED DATE

5 CONFIDENTIAL COMMUNICATIONS Due to the nature of our specialty, we are treating you as a couple. Since we may need to contact either of you in regard to appointments or results pertaining to you (individually or as a couple), we ask that each of you direct the clinic as to whom and where we may release your information. It is important that you list each other. Female Patient Phone number to leave messages: _ I authorize the release of my protected health information over the telephone to the following individuals: Name of person: Relationship: Date of Birth: Name of person: Relationship: Date of Birth: By providing an address, I authorize IVF Michigan Rochester Hills & Flint PC to send confidential information to the address provided: Patient Signature: Date: Male Patient Phone number to leave messages: _ I authorize the release of my protected health information over the telephone to the following individuals: Name of person: Relationship: Date of Birth: Name of person: Relationship: Date of Birth: By providing an address, I authorize IVF Michigan Rochester Hills & Flint PC to send confidential information to the address provided: Patient Signature: Date: IVF MICHIGAN ROCHESTER HILLS & FLINT, P.C.

6 Page 1 of 5 Female History Form Name: Date: Occupation: Referring Physician: Date of Birth: Age: Race/Ethnicity: Height: Weight: Relationship Status: BMI: Previous Marriage? Partner Name: Reason for coming to our clinic? (Please note that we do not provide donor services of any kind.) If trying to conceive, how long have you been trying? Do you have any significant medical problems outside of infertility? If so, what are they? ALLERGIES Do you have allergy to Latex? If so what happens? Do you have allergies to any medications? If so, what are they? Do you have any allergies to x-ray or IVP dye? Do you have any allergies to seafood? Do you have any allergies to peanuts? Do you have any allergies to sesame? Do you have any allergies to soy? MEDICATION HISTORY Please list any prescription medications you are currently taking: Please list any vitamins, dietary supplements, green tea, or other herbal medications: MENSTRUAL HISTORY Approximately how old were you when your periods started? What is the number days from first FULL flow day one month to next month first FULL flow day (ie, 28, 30, 45, irregular etc)? _ Flow description: Number of days bleed: Last menstrual period start date (First FULL day):

7 Page 2 of 5 Name: Date: MENSTRUAL HISTORY (continued) Do you have pain with your periods? Do you have bleeding between periods or after intercourse? Do you experience pre-menstrual symptoms? If so, what are they? Do you have unusual vaginal discharge? Do you recognize a change in your cervical mucous when you are ovulating? Have you taken oral contraceptives in the past? If so, what was it and for how long. Have you ever had irregular menses? If so, how old were you when it began and how long did it last? COITAL HISTORY How often do you have intercourse in a week? Do you time intercourse with ovulation? Do you have any difficulty or pain with intercourse? FERTILITY HISTORY Have you ever been pregnant? If so, please list each pregnancy, year and method of delivery (if applicable) and the outcome of each pregnancy: GYNECOLOGICAL HISTORY When was your last pap exam? Was it normal? Ever had an abnormal pap? How was it treated? When was your last breast exam? Was it normal? Ever have a mammogram? Reason for it and result: Do you have any gynecological problems? If so, please list: Do you have a history of any sexually transmitted diseases? If so, what and when:

8 Page 3 of 5 Name: Date: PREVIOUS INFERTILITY WORKUP - If you answer yes to any, we will need the records. Have you had Hysterosalpingogram (HSG)? If so, when was it done and what were the results? Have you had any gynecological/abdominal surgeries (e.g. laparoscopy, hysteroscopy)? If so, when was it done and what were the results? Have you had Endometrial Biopsy (EMB)? If so, when was it done and what were the results? Have you had a vaginal ultrasound? If so, when was it done and what were the results? Have you had a MRI/CT? When was it done and what were the results? Have you had any hormone blood testing? Date and Cycle day done: Results: FERTILITY TREATMENT HISTORY Clomid Dates of treatment: Number of Cycles: Monitored with: BBTC IUI (Intrauterine Insemination) Dates of treatment: Number of Cycles: Medication Used: ART (In-Vitro Fertilization) Dates of treatment: Number of Cycles: Medication Used: Dose: Ultrasound Progesterone Level ADDITIONAL FERTILITY TREATMENT HISTORY (If Necessary)

9 Page 4 of 5 Name: Date: GENERAL HISTORY QUESTIONS Do you have a history of an eating disorder? If so, please describe: Do you smoke? If yes, how much? Do you drink alcohol? If yes, how much? Do you use any kind of street drug or illicit drug? If so, please list: Do you have any history of psychiatric problems/emotional disturbances? Have you ever been hospitalized for psychiatric illness? Have you ever had surgery? If so, what was done and when? Have you ever been hospitalized for anything (besides above surgeries)? If so, what was the reason and when? Have you or anyone in your family had a problem with anesthesia (specifically malignant hyperthermia? Do you suffer from nutritional deficiency or electrolyte problems? GENERAL MEDICAL QUESTIONS Medical Problems Asthma Lung Disease Heart Disease Heart Murmur High Cholesterol Diabetes Hiatal hernia High Blood Pressure Kidney Disease Stroke Blood Clots (DVT, PE) Seizure Cancer Anemia (low iron) Sickle Cell Migraine Medical Problems Tuberculosis (TB) Thyroid Problems Birth Defects Hot Flashes Discharge from your nipples Hair growth on your face, abdomen, back or nipple area Temperature Intolerance Problems with your bowels Problems urinating Problems Sleeping Weight Gain or Loss Prior Blood Transfusions Arthritis Bruise Easily History of Gastric Bypass

10 Page 5 of 5 Name: Date: FAMILY HISTORY Diabetes Twins Infertility Problems Genetic abnormality (birth defects) Blood Clots Cancer Family History of Endometriosis OFFICE USE ONLY O Gyn Scan O Mock Cath O HSG O Saline Sonogram O MRI O CT O IVP O Lumbral Sacral X-Ray COMMENTS/DIAGNOSIS: Does patient need antibiotic coverage before procedure? Does patient need cervical suture before ART? Does patient need cervical cerclage with pregnancy

11 Name Date ORAL CONTRACEPTIVE CHECKLIST Does the Patient Have: History of blood clots? An allergy to oral contraceptives/estrogen? Abnormal Thrombophelia Profile? History of Migraines or Headaches? History of Liver Disease? Current Medications: Pregnancy Category:

12 Page 1 of 2 Male History Form Name: Date: Occupation: Date of Birth: Age: Race/Ethnicity: Height: Weight: Relationship Status: Re BMI: Previous Marriage? How many children do you have: With current partner? From previous relationship? ALLERGIES Do you have allergies to any medications? If so, what are they? MEDICATION HISTORY Please list any prescription medications you are currently taking: Please list any vitamins or herbal medications you are currently taking: GENERAL HISTORY QUESTIONS Do you smoke? If yes, how much? Do you drink alcohol? If yes, how much? Do you/have you used any kind of street drug or illicit drug? Please list: Do you have any history of psychiatric problems/emotional disturbances? Have you ever been hospitalized for psychiatric illness? Have you ever had surgery? If so, what was done and when? Have you ever had exposure to radiation or toxic chemicals? Do you have a history of hormone or steroid use? COITAL HISTORY Do you have difficulty with erection? Do you have difficulty with penetration? Do you have difficulty with ejaculation? Do you have pain with intercourse?

13 Page 2 of 2 Name: Date: PREVIOUS INFERTILITY TESTING Have you ever had a semen analysis done? Date: Result: Have you ever had any blood hormonal testing done? Date: Test&Results: GENERAL MEDICAL QUESTIONS Medical Problems Asthma Lung Disease Heart Disease Heart Murmur High Cholesterol Diabetes High Blood Pressure Kidney Disease Stroke Blood Clots Seizure Cancer Anemia (low blood) Sickle Cell Thyroid Problems Prior Blood Transfusions Arthritis FAMILY HISTORY Infertility Problems? If yes, please describe: Any genital abnormalities? OFFICE USE ONLY Semen Analysis FSH LH PRL TSH T Other: