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.
If you go by something other than your legal name, please indicate here:
Address: Apt./Condo #:
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
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:
In case of an emergency notify:
Relationship to patient:
Other Contact Phone:
Prescription Pharmacy Name:
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:
Reason for Visit:
Are you currently having problems with any of the following (please check all
If still having cycles: How many days apart?
How many days do they last?
Current Menstrual Problems:
Bleeding between periods
Date of last pap smear:
Date of last mammogram (if applicable):
Sexually Active: yes
Not Currently never
Sexual partners are:
Not Necessary None
Birth Control: Other
Primary Care Provider or Family Physician:
May we exchange medical information with your PCP?
Number of Pregnancies:
Number of Deliveries:
Number of living children:
Type(s) of Delivery: C-Section - how many Vaginal - how many
Have you ever had any of the following (if yes, please specify the number of
Ectopic Pregnancy ,
Please indicate if you have had any of the following procedures and the year
Other gynecological procedures (please list):
Have you ever had an abnormal Pap Smear?
yes no Year
of abnormal Pap?
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
Total number of male sexual partners in your life:
Infections: Do you currently have or do you have a history of the following
(please indicate year)
Herpes (number of outbreaks per year:)
Any history of physical or sexual abuse / assault or concerns in your current
Past Medical History: (Hypertension, Diabetes, Asthma, Injuries, Blood
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
Vitamins: None Calcium Multivitamin Vit
B Vit C Vit
E Vit A Iron
Herbal / Natural Supplements:
Graduate School Other:
Live with: Alone
Type Of Diet:
Low Fat / Carbohydrate / Cholestrol
per day for years
Past Smoker: no
pack(s) per day for
years year quit
servings every: day
servings per day
Drug Use: no
Do you have a living will (advanced directive):
deceased (from )
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
Are you interested in screening for sexually transmitted diseases? (You will
want to check insurance coverage before blood is drawn)
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
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.