Patient Information

Today's Date Date of Birth Patient Name

Social Security #

Home Address City

State

Zip Code

State

Zip Code

Work Address City Home Phone

Work Phone

Cell Phone In case of Emergency Please Notify: Name Address Phone Federal privacy rules require that you tell us how to contact you with information, lab results, appointment changes, and other information that is crucial to your care with Family Planning Associates Medical Group. Please check all that apply. The best way to telephone me is:

If you have to leave a message, say...

Call my home number Call my work number Call my cell number

"Family Planning Associates called" "your doctor's office called" "Casey called" (this is our 'code' for a call from this clinic)

Never call me Please list any other way to reach you I understand that staff may periodically need to contact me about test results or other information about my care with Family Planning Associates. I have made my preferences known about how to contact me. I also understand that critical situations may arise that require Family Planning Associates to make contact with me quickly. If unable to do so, I understand that Family Planning Associates may send certified mail to my home address as a way to make direct contact with me. By signing below I agree to Family Planning Associates' contact procedures.

Patient Signature

Witness

Parent or Guardian

Date and Time

How did you hear about Family Planning Associates? Yellow Pages Internet Referred by Dr.

Patient contact information rev 2014-0422

Been here before Referred by a friend Saw ad in

Radio Ad Other

State of Arizona Required Information

Arizona law requires that we collect and report the following information. This information is kept entirely confidential and your name will not be included when it is reported to the state. Patient Name Age How many years of education have you had, including grade school, college, graduate or professional school? No

Yes

Are you a resident of Arizona?

If yes, in what county do you live? If you are not a resident of Arizona, are you a resident of the United States? Are you of Hispanic origin?

Yes

No

No

Yes

Please indicate your race. Check all that apply: White

Asian

American Indian

Native Hawaiian or other Pacific Islander

Black or African American

Other

Are you married?

Yes

No

How many times have you been pregnant? Do not include this pregnancy. How many births have you had? How many abortions have you had? Do not include the abortion you are having today How many miscarriages have you had? PATIENTS DO NOT WRITE BELOW THIS LINE

Date of Abortion

Physician

Gestational age Indication elective Procedure suction D&C

medical mother D&E

medical fetus anencephaly MAB

Complication? Pre-existing medical problem that would complicate pregnancy?

State Required Information rev 2014-0303

medical fetus spina bifida

medical fetus other

M e d i c a l H i story Patient Name

Date

Age

How many times have you been pregnant, including this time? Please indicate below how your previous pregnances ended. # of live births

# of miscarriages

Have you ever had an ectopic or tubal pregnancy?

# of abortions Yes

# of c-sections

No

Have you ever had complications after childbirth, abortion, or miscarriage, including excessive bleeding? No explain Yes When did your last menstrual period start?

Yes

Was it a normal period?

Have you had any bleeding since your last period?

Yes

No

No

What birth control methods have you tried? Please list any operations that you have had including c-sections, D&C's, and procedures on your cervix: Have you ever had an operation to burn or freeze the lining of your uterus to stop your periods?

Are you allergic to latex?

Yes

Are you currently on any medications?

No Yes

No If yes, please list them below:

Do you use any recreational drugs such as cocaine, heroin, methamphetamine, etc.? If yes, which drug(s)? Do you smoke?

Yes

No

No If yes, please list the medications and type of reaction below:

Yes

Are you allergic to any medications?

Yes

Yes

No

When did you last use? No

Are you currently breastfeeding?

Yes

No

Please check if you have, or have had any of the following? Reaction to iodine

Heart disease

Seizures or epilepsy

Reaction to novacaine or other anesthetics

Heart murmur

Pelvic inflammatory disease (PID)

Hepatitis

Chlamydia

High blood pressure

Gonorrhea

HIV/AIDS

Genital warts

Kidney disease

Herpes

Migraine headaches

Syphilis

Mitral valve prolapse

Other

Anemia Asthma Bleeding tendencies Blood transfusions Blood clots in your legs or lungs Breast lumps or tumors

Psychiatric illness

Diabetes

I certify that the information I have provided is true, correct, and complete. Patient signature

Date

ROS History reviewed with patient Physician signature History rev 2014-0921

Date

Counseling Information

Patient Name

Date

You have made the choice to end your pregnancy today. This may have been a difficult decision for you. You will meet with a counselor who will help you with any questions, concerns or conflicts you might have. Answering the following questions can help us with your particular situation. Of course, all information is confidential. 1. Have you talked to anyone about your decision to have an abortion? If so, who? Physician

Counselor

Family

Friend

Partner

Other

2. Who is supportive of your decision? Family

Friend

Partner

Nobody

Other

3. Do you feel that anyone has pressured you into having an abortion? Yes

No

If yes, please explain below (who, how, why?)

4. Are you sure you want to have an abortion? Yes

No

5. Is there anything else you think we should know that would assist us in your care? Yes

No

Please explain

6. What method of birth control would you like to try today? Counselor's comments

Counselor's signature Physician's Comments

Physician's signature Counselng Information rev 2013-1118

Patient Privacy Notice

In accordance with the Federal Privacy Law (HIPPA), Family Planning Associates keeps medical information and records confidential and will only use them for patient treatment, health care operations, and billing purposes. Treatment: Our physicians, clinicians, and staff will use your medical information to give you the best possible care. Health Care Operation: Family Planning Associates will use this information for appropriate follow-up care, patient notification, statistical and regulatory requirements, and internal quality assurance programs. Billing Purposes: Family Planning Associates will use your medical information to bill the appropriate third party or parties for your care.

Disclosure of Information with Extenuating Circumstances 1. Health information will be given to family members in case of an emergency or under other circumstances with proper authorization and documentation. 2. Health information may be given to other physicians or institutions under emergency situations. 3. Information may be given to proper authorities when neglect or abuse is alleged or suspected. 4. Information may be provided to courts or other agencies when a subpoena is given to this office. I understand that if I have any questions I can speak to a Family Planning Associates Privacy Officer. I understand and agree to the above Privacy Policy.

Patient Signature

Witness

Patient name - Printed

Date and Time

I agree to allow Family Planning Associates to contact my referring physician for the purpose of continuity of care. Yes

No

Patient Privacy notice rev 2014-0422

N/A

Initials

Statement of Patient Rights

All women having an abortion in Arizona have the following rights: 1. To refuse treatment or withdraw consent for treatment; 2. To have medical records kept confidential; 3. To be informed of: a. Billing procedures and financial liability before abortion services are provided; b. Proposed medical or surgical procedures, associated risks, possible complications and alternatives; c. Counseling services that are provided in the physical facilities; and d. If an ultrasound is performed, the right to review the ultrasound results with a physician, a physician assistant, a nurse practitioner, or a registered nurse before the abortion procedure. I acknowledge that I have read and understand my rights as a patient as indicated above. _______________________________________ Signature of patient _______________________________________ Date

Patient Rights

Abortion Based on Gender or Race

Arizona law prohibits a physician from providing an abortion based on the sex or race of the fetus or the race of either parent. It also prohibits a physician from accepting payment for an abortion sought for those reasons. Because of this law, we are asking our patients to sign a statement affirming that they are not seeking an abortion because of the sex or race of the fetus, the race of the father, or their own race.

Certification That Abortion Is Not Being Performed On The Basis of Sex or Race I, ________________________________ (patient name), certify that my decision to have an abortion is not based on the sex or race of the fetus, the race of the father, or my own race. I further certify that the abortion is not being financed because of the sex or race of the fetus.

___________________________________________ (Patient Signature) ___________________________________________ (Date)

Race or Gender Certifcation