Azalea Women’s Healthcare
Date _____/______/______
HISTORY FORM Legal Name ___________________________________________
Date of Birth _______/_______/________
Previous last names __________________________________________________________________________ Race: ___White ___Black/African American ___American Indian ___Asian Other_____________________ Ethnic background: ___Hispanic or Latino ___Not Hispanic or Latino ___Declined Other_______________ Any cultural or religious beliefs that may affect your medical care? ______________________________________ Emergency contact(s) name _____________________________________________________________________ Address & phone number of emergency contact _____________________________________________________ ____________________________________________________________________________________________ Your preferred Pharmacy Name, Address and Phone Number: ______________________________________ ____________________________________________________________________________________________ Reason for office visit today:____________________________________________________________________ Date of Last Pap Smear ______/______/______
Date of Abnormal Pap Smear ______/______/______
Please provide approximate dates of any previous radiological examinations from the list below: Mammogram ____/____/____
Bone density ____/____/____
Colonoscopy ____/____/____
Have you had any of the following immunizations/vaccines: ____MMR (Measles/Mumps/Rubella) ____ Gardasil
____Tetanus booster
____Meningitis
Have you had the Chicken Pox or been vaccinated for it? ________________________________________ Please list any medical conditions you may have (asthma, diabetes, hypertension, STD’s, etc.): ____________________________________________________________________________________________ ____________________________________________________________________________________________ Please list any surgical procedures/operations you have had and the dates they were performed: Date
Operation
______________________
_________________________________________________________
______________________
_________________________________________________________
______________________
_________________________________________________________
Please list all of your medications, the doses, and how frequently you take them: Medication
Dose/Strength
Frequency
_____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________
Have you had allergic reactions to any medications? If so, please list: Name of medication
Reaction
___________________________________
___________________________________________________
___________________________________
___________________________________________________
___________________________________
___________________________________________________
REPRODUCTIVE HISTORY: How old were you when you had your first period? ________ Date of 1st day of last period _____/_____/_____ How frequent are your periods? (How many days from beginning of one to the next?) ____________________ Duration (usual number of days of flow) ____________ Flow: (circle one) Heavy Moderate Light Do you have bleeding/cramping/spotting between periods? Yes or No Do you feel as though your periods impact the quality of your life? Yes or No What do you use to keep from getting pregnant? __________________________________________________ Are you planning another child? ____ Within this year ____ Within 5 years ____ Within 10 years ___ No If you are menopausal, at what age did you have your last period? ___________________________________ Do you ever leak urine when you cough, laugh or sneeze? Yes or No Have you ever had (please circle any that apply): Syphilis; Sores; Gonorrhea (G.C., “Clap”, or “Drip”); Chlamydia; Herpes (blisters); Trichomonas; HPV (“warts”); Hepatitis; pelvic or tubal infection or inflammation (PID); or HIV
PREVIOUS PREGNANCIES: (first to last) Date:
Delivery: Vaginal, C-Section, Miscarriage, Abortion
Sex of Baby:
Baby’s Birth Weight:
Mother’s Weight Gain:
Hours of Labor:
Complications: For Mother For Baby
______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________
FAMILY HISTORY List any family members (blood relatives only) with the following medical problems (list relationships, ie mother (M), father (F), sister (S), brother (B), maternal grandmother (MGM), maternal grandfather (MGF), paternal grandmother (PGM), paternal grandfather (PGF), etc.) CARDIAC Stroke _________________________________ Heart disease ___________________________ High blood pressure ______________________ High cholesterol _________________________ Blood clots _____________________________ Pulmonary embolism _____________________
NEOPLASMS/MALIGNANCY Ovarian cancer __________________________ Uterine cancer __________________________ Breast cancer ___________________________ Colon cancer ___________________________ Other malignancy _______________________ Cervical cancer _________________________
DIGESTIVE/GASTROINTESTINAL Celiac disease __________________________ Colon polyps ___________________________ Familial polyposis _______________________ Ulcerative colitis ________________________ Crohn’s disease _________________________ Hepatitis ______________________________
NEUROLOGIC Alzheimer’s disease ______________________ Parkinson’s disease ______________________ Seizure disorder _________________________ PSYCHIATRIC Bipolar disorder _________________________ Depression _____________________________ Schizophrenia __________________________ Alcoholism _____________________________
ENDOCRINE Diabetes (sugar) _________________________ Thyroid disorder _________________________ Graves disease __________________________
RESPIRATORY Tuberculosis ___________________________ COPD ________________________________ Emphysema ____________________________ Lung Cancer ___________________________
HEMATOLOGIC Factor VIII disorder ______________________ Von Willebrand’s disease __________________ Sickle cell disease/trait ____________________ Hereditary spherocytosis __________________
OTHER Cystic fibrosis __________________________ Scleroderma ___________________________ Lupus ________________________________ ______________________________________
MUSCULOSKELETAL Arthritis _______________________________ Osteoporosis ___________________________ Osteopenia _____________________________ SOCIAL HISTORY:
Do you ever drink alcohol? Yes/No How often on average? ____________ How many drinks per time? _____ Have you ever smoked? Yes/No How many years? ____ How many per day? ____ When did you quit? _____ Do you use any other non-prescription drugs? Yes/No If yes, what type? ________________________________ How old were you when you had sex for the first time? _______________ How many sexual partners have you had in your lifetime? (circle one) Last grade completed? ____________________
Yellow Pages
TV Commercial
2–5
More than 5
Did you attend college? Yes/No
How did you find out about or choose us? (circle) Physician Billboard
0–1
Newspaper
Friend
Azalea Website
WCTV HealthLinks
Other ____________________________________
What is your occupation? _______________________________________________________________________ What is your marital status? (circle)
Single
Dating
Engaged
Married
Divorced
Widowed
OFFICE ONLY: Height _____’ _____” Weight _______ BP _____/_____ HGB _____ U/A _____ Temp _____ G _____ P _____ ______________________________________________________________________________________________________________
NOTES:
Azalea Women’s Healthcare Patient Information Name: ___________________________________
Home Phone:______________________________
Address:__________________________________
Work Phone: ______________________________
City, State, Zip: ____________________________
Alt. Phone: _______________________________
Date of Birth: _____/_____/_____
Marital Status: ( )Single ( ) Married ( ) Divorced
Age:______
Social Security # _______-_______-_______ Driver’s License #__________________________
Race: ( ) Black/African American ( ) White ( ) Other ______________________ ( ) Declined Ethnicity: ( ) Hispanic ( ) Non-Hispanic
Patient Employment
Emergency Contact
( )Employed ( )Retired ( ) Unemployed
Name: __________________________________
Employer:_________________________________
Phone #: ________________________________
Responsible Party
(If other than patient)
Name:___________________________________
Employer:________________________________
Address: _________________________________
Work Phone: _____________________________
City, State: _______________________________
Alternate Phone: __________________________
Date of Birth: _______/_______/_______
Social Security # ______-______-______
Primary Insurance
Check One. ( )BCBS ( )CHP ( )Vista ( )MCR ( )MCD ( )Other _________________
Policy Holder : ____________________________
Relationship to Patient:_____________________
Insurance Co:_____________________________
Policy ID # ________________Group #________
Policy Holder Date of Birth: ______/_____/______
Policy Holder SS # ______-______-______
Medicare Secondary Insurance ( ) Same as Patient ( ) Same as Guarantor Policy Holder:_____________________________
Relationship to Patient:_____________________
Insured Phone:____________________________
Social Security # ______-______-______
Insurance Co:_____________________________
Policy ID # ________________Group #________
I, the below signed patient, certify that the above information is correct and understand that if any information is incorrect, I will be financially responsible for all costs incurred from the visit. I understand that Azalea Women’s Healthcare will file my insurance as required by contracts, where applicable, and that I am responsible for full payment to Azalea Women’s Healthcare for services provided. Furthermore, I authorize Azalea Women’s Healthcare to release pertinent medical records for documentation of services in order to process medical insurance claims.
Signature __________________________________________
Date ______/________/________
Azalea Women’s Healthcare OBSTETRIC HISTORY Name __________________________ 1. Date of first day of last menstrual period: ____/____/____
Date __________________ Was this a normal period?
__ yes __ no
2. What day did you have your first positive pregnancy test (including a test done at home)? ____/_____/_____ 3. What was your weight before you got pregnant? ______________ 4. Have you had any vaginal bleeding or cramping?
__ yes __ no
5. Have you been exposed to x-rays or drugs since your last menstrual period (LMP)?
__ yes __ no
6. Have you felt the baby move yet? If so, what was the first day you felt movement? ______________
__ yes __ no
7. Have you ever smoked? If so, how many years? ____ How many per day? ____ When did you quit? ______
__ yes __ no
8. Do you ever drink Alcohol?
__ yes __ no
If so, how much? ___________________
9. Do you use any street drugs or have you used them in the past?
__ yes __ no
If so, what and when? __________ 10. Do you take any medications, drugs, or herbal therapies? __ yes __ no Please include prenatal vitamins, iron, over-the-counter medications, and “natural” products. _________________________________________________________________________ 11. Do you or your partner have a history of herpes or any other sexually transmitted disease? If so, what?____________________________
__ yes __ no
12. Have you ever had diabetes or thyroid disease?
__ yes __ no
13. Have you ever had high blood pressure or heart disease (including heart murmur)?
__ yes __ no
14. Have you ever had chicken pox or have you been vaccinated for it (varicella vaccine)?
__ yes __ no
15. Will you be less than 15 or more than 35 years old when your baby is born?
__ yes __ no
16. Are you or your partner Black, Mediterranean, or Asian?
__ yes __ no
17. Are you Jewish? If yes, are you of Central or Eastern European background? (circle)
__ yes __ no
18. Have you, your family, your baby’s father’s family, or any blood relative had: a. b. c. d. e. f. g. h.
Cerebral palsy or epilepsy? Down’s syndrome (mongolism) or mental retardation? Spina bifida or meningomyelocele (open spine) or hydrocephalus (water head)? Hemophilia or bleeding disorders? Muscular dystrophy? Cystic fibrosis? Other inherited disorders? Any babies been born in your family or your baby’s father’s family with any problems? If so, what?_______________________________
19. Have any women in your family (your blood relatives) had any problems having babies? If so, who and what.______________________________________________________
__ yes __ yes __ yes __ yes __ yes __ yes __ yes __ yes
__ no __ no __ no __ no __ no __ no __ no __ no
__ yes __ no
20. Do you have a history of infertility, miscarriage, stillbirth, or any serious pregnancy complications? If so, what.___________________________________________________________ __ yes __ no
21. Do you feel safe in your home?
__ yes __ no
22. Have you had any blood tests or ultrasounds during this pregnancy? If so, when & where._______________________________________________________
__ yes __ no