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Saratoga OB/GYN at Myrtle StreetPATIENT REGISTRATIONFIRS T NAME (LEGAL)PREFERRED FIRS T NAMES TREET ADDRES SMILAS T NAMECITYHOME PHONEZIP CODECELL PHONEWORK PHONEEMAIL ADDRES SRACE (please circle one)WHITEBLACKAMERICAN INDIANAS IANOTHERDATE OF BIRTHETHNICITY (please circle one)HIS PANIC ORIGINNOT OF HIS PANIC ORIGINOTHERPHARMACYLANGUAGE PREFERENCE (please circleone)ENGLIS HOTHERREFERRING DOCTORRELATIONS HIP S TATUS (please circle one)NEVER MARRIEDMARRIEDDIVORCEDS EPARATEDDOMES TIC PARTNER WIDOWED OTHERGENDERPRIMARY DOCTOREMPLOYERPRIMARY INS URANCE INFORMATIONPRIMARY INS URANCE COMPANY NAMEINS URANCE COMPANY ADDRES SNAME OF INS URANCE POLICY HOLDERINS URANCE GROUP #INS URED'S DATE OF BIRTHINS URED'S POLICY #INS URED'S EMPLOYERPATIENT INS URANCE POLICY #EMPLOYER'S ADDRES SRELATIONS HIP TO INS UREDEFFECTIVE DATE OF INS URANCE PLAN IF AUTO OR WORK RELATED, DATE OFINJURYS ECONDARY INS URANCE INFORMATIONS ECONDARY INS URANCE COMPANY NAMEINS URANCE COMPANY ADDRES SNAME OF INS URANCE POLICY HOLDERINS URANCE GROUP #INS URED'S DATE OF BIRTHINS URED'S POLICY #INS URED'S EMPLOYERRELATIONS HIP TO INS UREDHOW DID YOU HEAR ABOUT US ?PATIENT INS URANCE POLICY #EMPLOYER'S ADDRES SEFFECTIVE DATE OF INS URANCE PLAN IF AUTO OR WORK RELATED, DATE OFINJURY FRIEND/RELATIVE PHONE BOOK MAGAZINE AD INTERNET OTHERPLEAS E S PECIFY:
TODAY’S DATE:APPOINTMENT DATE:PATIENT LEGAL NAME: DATE OF BIRTH:PREFERRED NAME: GENDER:PRIMARY CARE PHYSICIAN: PHARMACY AND LOCATION:REASON FOR VISIT:CURRENT MEDICATIONS AND DOSAGE (including vitamins and over-the-counter):ALLERGIES (and type of reaction):MENSTRUAL HISTORY (answer all questions that apply to you) SELF CAREAge at first menstrual period:Have you had Gardasil vaccine?How many shots:First day of last period:Do you have regular checkups?How many days between periods?Date of last pelvic/pap exam:How many days does period last?Date of last mammogram:Is your flow heavy, light, moderate?Date of last bone density scan:Any menstrual symptoms?Date of last colonoscopy:PROCEDURESHave you ever had an abnormal pap smear? Yes No If yes, when?Have you ever had any procedure to your cervix (i.e., colposcopy, LEEP)? Yes NoIf yes, please specify: When?BIRTH CONTROLCurrent Birth Control Method: (Check which one applies) None Condoms Pills NuvaRing Nexplanon Depo Shot Essure Adiana IUD: Year placed Tubal Ligation/Salpingectomy Hysterectomy Other:MENOPAUSE HISTORY (Please answer all questions that apply to you.)Age at menopause:Are you currently or have you ever taken hormones?If yes, what?Symptoms of menopause: Hot Flashes or night sweatsIf yes, for how long? Sleeping difficulties Vaginal DrynessAre there any side effects? Decreased Libido Other:Are you currently pregnant? YesPREGNANCY HISTORYTotal # of Pregnancies:Weeks atDate ofdeliverybirth(Term 40)# of Premature Births:Baby'ssexWeightat birthHours inLabor No# of Miscarriages:Type ofDeliveryType ofAnesthesia# of Induced Abortions:Hospital & Name ofMD or CNMBaby'sName# of Living Children:Complications
Patient Name:PLEASE LIST ANY CHILDHOOD ILLNESSESChickenpoxMeaslesChickenpox - VaccineMumpsOther:RubellaScarlet FeverPLEASE CHECK ALL MEDICAL PROBLEMS YOU HAVE OR HAVE HAD:Please check box to LEFT of illness or problem.Abdominal Aortic AneurysmAshkenazi JewishAcneADHDAIDSAlcoholismSeasonal AllergiesAlzheimer's DiseaseAnemiaAnginaArteriosclerosisArthritis, RheumatoidArthritis, OsteoAsthmaBipolar DisorderAtrial FibrillationBlood TransfusionsCancer* (List below.)Carotid Artery StenosisCataractsCerebrovascular Accident (CVA)CirrhosisCNS TumorsColitisColon PolypsCongestive Heart FailureCOPDCoronary Artery DiseaseCrohn’s DiseaseDepressionDermatitisDiabetes- Insulin DependentDiabetes- ug AddictionEating DisorderEmphysemaEpilepsyEsophagitisFibrocystic Disease of outHard of HearingHeart Attack (MI)Heart DiseaseHeart FailureHeart MurmurHemophiliaHepatitis AHepatitis BHepatitis CHerpesHiatal HerniaHIVHodgkin's eInfertilityKidney DiseaseKidney StonesLeukemiaLiver DiseaseLupusMental IllnessMigraine with auraMigraine without auraMitral Valve Prolapse (MVP)Multiple Sclerosis (MS)ObesityOsteoporosisPeptic Ulcer DiseasePalpitationsPancreatitisParkinson's DiseasePeripheral Vascular monary EmbolismRheumatic FeverScoliosisSeizure DisorderSickle Cell AnemiaStrokeSyphilisTransient Ischemic Attack (TIA)Thyroid DiseaseHypothyroidismHyperthyroidismGrave’s DiseaseTuberculosisTumorsUlcersVenous InsufficiencyLung DiseaseVertigo*PLEASE LIST ANY CANCER HISTORYDATETYPE OF CANCERTHERAPY
Patient Name:SURGERIES AND PROCEDURESDATETYPE OF S (Please list all with dates.)DATETYPE OF HOSPITALIZATION PHYSICIANHOSPITALCOMPLICATIONSASSISTIVE DEVICES (List any assistive devices you wear or use, i.e. hearing aids, contact lenses, glasses, walkers.)FAMILY MEDICAL HISTORYCANCER TYPERELATIONSHIPAGE AT DIAGNOSISLIVING (Yes /No)If no, age deceased Breast cancer Ovarian cancer Endometrial cancer Colon cancer Pancreatic cancer(Please list all family illnesses.)RELATIVEFatherMotherPaternal GrandmotherPaternal GrandfatherMaternal GrandmotherMaternal GrandfatherBrothers#Sisters#Other (Children, Aunts,Uncles, Nieces,Nephews, Cousins)ILLNESSES & AGE AT DIAGNOSISLIVING (Yes /No)If no, age deceased
Patient Name:SOCIAL/PERSONAL HISTORYHighest level of education attained:Marital Status:Are you currently working? Yes NoOccupation:Do you feel safe at home? Yes NoIf no, please explain:Has anyone ever hurt you in any way? Yes NoIf yes, please explain: Yes NoDo you smoke? (Cigarettes or E-Cigarettes)If yes, # cigarettes per day:If yes, how important is it for you to quit smoking?(Circle one)1 2 3 4 5 6 7 8 9 10If yes, how ready are you to quit smoking?(Circle one)1 2 3 4 5 6 7 8 9 10 Yes NoIf yes, # cigarettes per day:Do you drink alcohol? Yes NoIf yes, # drinks per day:Do you drink caffeine? Yes NoIf yes, type and # cups per day:Do you use Marijuana? Yes No If yes, how often:Do you use drugs? Yes NoIf yes, type and how often:Do you exercise? Yes NoIf yes, type and how often:If no, did you previously smoke?Are you currently sexually active? Yes NoTotal # of sexual partners in lifetime:Is your sexual partner MaleDo you have any history of sexually transmitted Yes FemaleIs intercourse painful? Yes No Other: No If yes describe:diseases (STD’S)?What is your gender identity? Female Male Other:Sexual Orientation: Straight/Heterosexual Gay/Lesbian/Homosexual Bisexual Other (please specify):Are there any issues you would like to discuss today?Thank you for trusting us with your care
friend/relative phone book magazine ad internet other please specify: _ if auto or work related, date of injury if auto or work related, date of injury patient registration primary insurance information saratoga ob/gyn at myrtle street secondary insurance information .
