GYN PATIENT REGISTRATION Note: This form may be completed manually or on your computer. To complete this form on the computer: 1.Type your answer in each field. 2. Save your work often on your computer or device. 3. Print the completed form and bring it with you to your first appointment. PATIENT INFORMATION NAME (FIRST, M.I., LAST) SSN BIRTH DATE SEX MAILING ADDRESS APT# CITY STATE ZIP M F HOME PHONE XXX-XXX-XXXX WORK PHONE XXX-XXX-XXXX CELL PHONE XXX-XXX-XXXX EMAIL ADDRESS (EXAMPLE@TEST.COM) PREFERRED CONTACT METHOD (REQUIRED) MARITAL STATUS RACE ETHNICITY LANGUAGE CELL HOME WORK EMAIL TEXT PRIMARY EMPLOYER EMERGENCY CONTACT EMERGENCY PHONE ADDRESS SUITE # TO WHOM WE MAY RELEASE MEDICAL INFORMATION CITY, STATE, ZIP PRIMARY CARE PHYSICIAN OCCUPATION STATUS REFERRING PHYSICIAN FT PT NOT EMPLOYED GUARANTOR/RESPONSIBLE PARTY (if different than patient) NAME (FIRST, M.I., LAST) SSN BIRTH DATE SEX MAILING ADDRESS CITY STATE ZIP M F HOME PHONE XXX-XXX-XXXX WORK PHONE XXX-XXX-XXXX CELL PHONE XXX-XXX-XXXX EMAIL ADDRESS (EXAMPLE@TEST.COM) PREFERRED CONTACT METHOD (REQUIRED) CELL HOME WORK EMAIL TEXT RELATIONSHIP TO PATIENT PRIMARY INSURANCE NAME OF INSURANCE COMPANY POLICY # NAME OF POLICY HOLDER BIRTH DATE GROUP # RELATIONSHIP TO PATIENT EFFECTIVE DATE GROUP NAME SECONDARY INSURANCE NAME OF INSURANCE COMPANY POLICY # NAME OF POLICY HOLDER BIRTH DATE GROUP # RELATIONSHIP TO PATIENT EFFECTIVE DATE GROUP NAME FINANCIAL POLICY: Payment in full or co payment is expected at the time of service. Services provided that are not a covered benefit of your health plan will be your responsibility. You may also be required to pay deductible, co-insurance, supplies, at the time of service. For patients without insurance, payment is due at the time of service. This includes initial urological consultation, office visits, medications, supplies as well as diagnostic and therapeutic procedures. An approximate cost for anticipated services will be provided to you at the time of the scheduling of your appointment or procedure. Payment may be made by cash, check, or credit card. Exceptions to this policy will be made by the urgency and severity of your medical condition and no patient will be denied emergent medical care. ADDITIONAL OFFICE CHARGES NOT COVERED BY INSURANCE INCLUDE: No-Show Appointment Fee $25.00 (Cancellations require 24 hour notice. Discharge from practice occurs after third no-show) Returned Check Fee $25.00 Form Fees (per form) $25.00 (Forms include: Disability, Life Insurance, Health Insurance, Jury Duty, Work & School Excuses $10.00 Assisted Living Forms, Leave of Absence Forms) Any questions concerning this policy are to be coordinated through the Administration Office: Urology Associates of the Central Coast, Administration Office, 225 Prado Rd. Ste. D, San Luis Obispo, CA 93401 (805) 786-2500 ext. 116 CONSENT TO TREATMENT/RELEASE OF INFORMATION: I grant Urology Associates of the Central Coast the authority to administer medical treatment and perform medical procedures as deemed necessary; and the authority to access Private Health Information (PHI) via Health Information Exchanges (HIE) including, but not limited to pharmacy, hospital and other physicians records involved in my care. I authorize the release of medical information to my insurer, or the insurer s agents to process my payments for service. To the best of my knowledge, all of the information above is true and correct. ASSIGNMENT OF BENEFITS: I hereby assign all benefits payable by my insurance company to Urology Associates of the Central Coast. PATIENT /RESPONSIBLE PARTY SIGNATURE DATE RELATIONSHIP TO PATIENT
GYN HEALTH HISTORY DATE MEDICAL HISTORY Please indicate all past and current medical conditions (check all applicable). Alcohol Abuse Drug Abuse Infertility Allergies Eating Disorder Irritable Bowel Syndrome Anemia Emphysema Kidney Disease Anxiety Fibromylagia Kidney Infection Autoimmune Disorder, Type: Gallstones Low Thyroid Bipolar Gastritis Macular Degeneration Bladder Infection, Chronic Glaucoma Mental Retardation Bronchitis Headache Migraine Headache Cancer, Breast Heart Attack Obesity Cancer, Cervical Heart Disease Osteoarthritis Cancer, Colon Heart Failure Osteopenia Cancer, Ovarian Hematologic Disorder Osteoporosis Cancer, Uterus Hemorrhoids Pancreatitis Cancer, other: Hepatitis A Pulmonary Embolism Cirrhosis Hepatitis B Reflux Disease Deep Vein Thrombosis Hepatitis C Schizophrenia Dementia Hernia Seizures Depression High Blood Pressure Sexually Transmitted Disease Diabetes High Cholesterol Stroke Diverticulitis High Thyroid Tuberculosis Diverticulosis Incontinence Ulcers REVIEW OF SYSTEMS Are you currently experiencing any of the following (check all applicable)? Anxiety Blood in Urine Blood in Stool Depression Burning with Urination Constipation Fatigue Frequent Urination Heartburn Headache Incontinence Nausea Fever Night Time Urination Vomiting Night Sweats Breast Lump Black Stool Weight Gain / Loss Breast Pain Abdominal Pain Genital Sores Chest Pain Rash Painful Intercourse Palpitations Cough, Chronic Pelvic Pain Shortness of Breath Vaginal Discharge PAST EXAMINATIONS Have you had a colonoscopy? If yes, what year?: Have you had a bone density scan (DEXA scan)? If yes, what year?: Bone density results: Normal Low Bone Desity Osteopenia Osteoporosis Cholesterol Level: Normal Low High PATIENT NAME BIRTH DATE
GYN HEALTH HISTORY DATE PATIENT NAME BIRTH DATE SOCIAL HISTORY Marital Status: Single Married Widowed Partnered Eduction: Primary High School 2yr College 4yr College Masters Doctorate Occupation: Languages spoken: English Spanish Other: Languages read: English Spanish Other: Diet: Nonspecific Low Fat Low Carb High Protein Vegetarian Other: Exercise Frequency: Days/Week Exercise Type: Are you sexually active? Partner(s): Male Female Both Number of Sexual partners: Do you douche? Current birth control type, if any: Have you had a sexually transmitted disease? Type: Have you been in an abusive relationship? Are you currently in an abusive relationship? Tobacco Use: Currently Past Never Packs/Day: # of Years: Are you ready to quit? Last Used: Alcohol Use: Currently Past Never Drinks/Day: # of Years: Do you have an alcohol problem? Last Used: Drug Use: Currently Past Never Type: # of Years: Do you have a drug problem? Last Used: Do you drink caffeinated products? Drinks/Day: Would you accept a blood transfusion if medically necessary? Are you Jehovah Witness? Do you have a living will, directive, or durable power of attorney for health care? If no, we recommend that you complete one. Do you wear a safety belt when riding in a car? Do you preform breast self-examinations on a regular basis? Do you take calcium and/or vitamin D regularly?
GYN HEALTH HISTORY DATE PATIENT NAME BIRTH DATE FAMILY HISTORY Have any of your blood relatives had these conditions (check all appropriate boxes)? Mother Father Grandmother Maternal Grandmother Paternal Grandfather Maternal Grandfather Paternal Brother Sister Children Alcoholism Anxiety Autoimmune Disorder Type: Bipolar Disorder Bleeding Tendency Breast Cancer Ovarian Cancer Uterine Cancer Colon Cancer Cancer, Other Type: Deep Vain Thrombosis Dementia Depression Diabetes Drug Addiction Eating Disorder Heart Attack Heart Disease Heart Failure Hypertension High Cholesterol Low Thyroid Action Osteoarthritis Osteoporosis Pulmonary Embolism Schizophrenia Epileptic Seizures Stroke Other:
GYN HEALTH HISTORY DATE CURRENT MEDICATIONS 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. NAME DOSE FREQUENCY INDICATION Preferred Pharmacy Location ALLERGIES Do you have any allergies to medications? NAME DOSE FREQUENCY REACTION 1. 2. 3. 4. GYN HISTORY Have you ever had an abnormal pap smear? If yes, what year? How old were you when your period started? How often are your periods? How long do your periods last? When was the first day of your last period? Do you have bleeding or spotting between periods? Do you have bleeding or spotting after intercourse? Do you have problems with your period? Do you have significant pain with your periods? Do you use medication to relieve the pain? Do you have other pelvic or abdominal pain any other times? If you have gone through menopause, how old were you? PATIENT NAME BIRTH DATE
GYN HEALTH HISTORY DATE OBSTETRICAL HISTORY (How many children have you delivered?) YEAR PATIENT NAME BIRTH DATE WEEKS GESTATION SEX BIRTH WEIGHT TYPE OF DELIVERY COMPLICATIONS Do you have any foster, adopted, or stepchildren? (Specify) Any miscarriages, abortions, or tubal pregnancies? SURGERIES AND HOSPITALIZATIONS (Please do no include childbirth) YEAR OPERATION HOSPITAL SURGEON Any other problems or concerns? PATIENT SIGNATURE: DATE: PROVIDER SIGNATURE: DATE: