Please provide as much information as possible here to help us create your patient record. The more comprehensive your responses, the better we can serve your needs. When finished, click "submit history" at the bottom.
Name:
If you go by something other than your legal name, please indicate here:
Address: Apt./Condo #:
City: State: Zip:
Home Phone: Work Phone: Cell Phone:
Which number would like to be primary? Home PhoneWork Phone Cell Phone May we leave messages at this number? yes no
Email Address (required):
Date of Birth: Age: SSN#: Sex female male
Who are you seeing today? Charles Downey, MD Carol Norton, MD Charmaine Gibson, MD Elayna Brooks, MDCori Poovey, NP Shirley Tran, NP
Insured (Name of Insurance Card Holder – Self, Spouse, Parent, etc.):
Insured's Date of Birth: Insured's SSN#:
Insured's Employer: Phone:
In case of an emergency notify: Phone:
Relationship to patient: Other Contact Phone:
Prescription Pharmacy Name: Phone:
Pharmacy address or closest intersection:
How did you hear about our office?
If referred to our office, by whom?
Your current Primary Care or Family Physician: Phone:
Last Period:
Reason for Visit:
Are you currently having problems with any of the following (please check all that apply):
Menstrual History: Hysterectomy Menopause
If still having cycles: How many days apart? How many days do they last?
Current Menstrual Problems: Heavy Bleeding Pain Clots Bleeding between periods
Date of last pap smear: Normal Abnormal
Date of last mammogram (if applicable): Where?
Sexually Active: yes Not Currently never Any Concerns? Pain Bleeding Dryness
Sexual partners are: Male Female both
Birth Control: Not Necessary None Condoms Pill/Patch/Ring Injection Tubal IUD Vasectomy Birth Control: Other
Primary Care Provider or Family Physician: May we exchange medical information with your PCP? yes no
Number of Pregnancies: Number of Deliveries: Number of living children:
Type(s) of Delivery: C-Section - how many Vaginal - how many
Largest baby:
Have you ever had any of the following (if yes, please specify the number of times): Miscarriage , Ectopic Pregnancy , Termination
Please indicate if you have had any of the following procedures and the year performed.
Other gynecological procedures (please list):
Have you ever had an abnormal Pap Smear? yes no Year of abnormal Pap?
Treatment: Repeat Pap Colposcopy/Biospy Cryotherapy LEEP/Cone Other
How old were you when you had your first period?
If menopausal, at what age did you have your last period?
List methods of birth control or hormone replacement therapy you have used in the past:
Total number of male sexual partners in your life: 0 1-4 5-10 11-20 >20
Infections: Do you currently have or do you have a history of the following (please indicate year) Chlamydia Gonorrhea Warts HPV Trichomonas Syphilis Herpes (number of outbreaks per year:)
Any history of physical or sexual abuse / assault or concerns in your current relationship? yes no
Past Medical History: (Hypertension, Diabetes, Asthma, Injuries, Blood transfusion, etc.)
Non-Gynecological Surgeries: (Colonoscopy, Gallbladder, Appendix, etc)
Immunizations (indicate the date):Tetanus Hepatitis B HPV(Gardasil)
Drug Allergies: (Sulfa, Penicillin, Myacins, etc)
Are you allergic to any of the following: Iodine IV dye Peanuts Latex
Current Medications
Vitamins: None Calcium Multivitamin Vit B Vit C Vit E Vit A Iron Others:
Over-the-counter medications: Herbal / Natural Supplements:
Occupation:
Education: High School College Graduate School Other:
Marital Status: Single Engaged Married Widowed Separated Divorced Significant Other
Live with: Alone Roommate Family Spouse Fiancé SignificantOther
Type Of Diet: Regular Low Fat / Carbohydrate / Cholestrol Diabetic Vegetarian Other
Exercise: no yes Type: Cardio Weights Other: # days/week
Smoke: no yes pack(s) per day for years
Past Smoker: no yes pack(s) per day for years year quit
Alcohol: no yes servings every: day week month year
Caffeine: no yes servings per day
Drug Use: no yes type and frequency
Do you have a living will (advanced directive): no yes
Mother: alive deceased (from )
Father: alive deceased (from )
If a screening test is ordered and returns to us as "abnormal", further testing may be done and will likely be applied to your insurance deductible. This includes testing ordered at “Annual” or Well Woman exams. We routinely check for Chlamydia with the Pap smear if you are 25 or younger per the American College of Obstetricians and Gynecologists (ACOG) recommendations.
We routinely check for Human Papilloma Virus (HPV) with the Pap smear if you are 30 or older at least every 3 years per ACOG and American Cancer Society recommendations.
Are you interested in screening for sexually transmitted diseases? (You will want to check insurance coverage before blood is drawn) Yes No
The following information must be provided at your appointment: insurance cards, Driver’s License or picture ID, and a major credit card. This information is necessary in order for our office to process your insurance claims more efficiently. By clicking "submit history" below, you acknowledge that appointments will be rescheduled for the following reasons: • If a patient is more than 15 minutes late for an appointment. • If a patient is unable pay for the office visit. • If children that need supervision from the staff (except for newborns) are brought to the appointment. • Rescheduling may be necessary in order for our staff to manage the schedule and for the courtesy of patients.
