Marshall Women's Center Registration Form

MARSHALL WOMEN’S CARE REGISTRATION FORM

PATIENT NAME: Birth date:

ADDRESS: Social Security #:

Street, Apt. No.

City: State: Zip:

Home Phone:( ) County: Sex: Race: Religion_______

MAIDEN NAME: (Single patients or male patients give mother=s maiden name)

Single ____ Married ____ Widowed ____ Separated ____ Divorced ____

PATIENT EMPLOYER

NAME: ADDRESS:

Employer Phone: ( )

Street, Appt.. No. City, State, Zip

Occupation:___________Employment Status: Full Time____ Part Time ____ Retired ____ Unemployed ____

PERSON TO NOTIFY

NAME: ADDRESS:

Phone: ( ) Relationship:

NEXT OF KIN (If same as person to notify leave blank)

NAME: ADDRESS:

Phone: ( ) Relationship:

GUARANTOR (Who is responsible for bill: Self or (Who is bringing pt in today if minor)NOT INSURANCE )

NAME: ADDRESS:

Phone: ( ) S.S. Number:

GUARANTOR EMPLOYER

NAME: ADDRESS:

EMPLOYMENT STATUS: OCCUPATION_________ EMPLOYER PHONE: ( )

IF PATIENT IS A MINOR WE NEED BOTH PARENTS EMPLOYMENT INFORMATION. THIS SECTION IS FOR THE PARENT THAT IS NOT LISTED IN THE GUARANTOR INFORMATION ABOVE.

NAME: ____________________________SS#__________________DATE OF BIRTH____________

ADDRESS_____________________________ RELATIONSHIP TO PATIENT___________

EMPLOYER ADDRESS _________________________________PHONE:_____________

EMPLOYMENT STATUS______________________

INSURANCE POLICY NUMBER COVERAGE NO. SUBSCRIBER REL OFFICE COPAY

Primary Care Physician: Reason for Visit:

READ AND SIGN

I hereby authorize payment directly to my physician=s office, of any Insurance coverage for treatment rendered, and authorize them to release any information necessary to process these insurance claims.

I understand that I am fully responsible for all social services and charges, including any balance due after payment of insurance, and that insurance coverage does not necessarily pay all charges.

I also understand that doctor and office fees are due and payable when services are rendered.

I, the undersigned, authorize treatment by the physician of this office.

SIGNATURE:

(If Minor, Parent or Guardian Signature)

DATE:

Type of Accident related to this visit: WHEN TREATMENT IS RELATED TO ACCIDENT MEDICARE, WORKMAN=S COMPENSATION OR OTHER LIABILITY

PATIENT EMPLOYED: Yes No

RETIRED: Yes No

SPOUSE EMPLOYED: Yes No

COVERED BY GROUP INSURANCE: Yes No

Medicare (Basis of entitlement) Age Disability Other

Liability A/A Comp Sports Injury

1. WORKMAN=S COMPENSATION Date of Accident:

Brief description of accident:

Employer: Phone #: ( )

Address: Phone #: ( )

Comp Carrier: Phone #: ( )

Verified: Yes No

Date Verified: By:

Contact Person (Name & Title):

Comments:

2. OTHER LIABILITY AND/OR SPORTS INJURY: Date of Accident:

Reason:

Responsible Party=s Name:

Address:

Phone #: ( ) Relationship:

Primary Insurance:

Policy Number:

Secondary Insurance:

Policy Number:

3. AUTO ACCIDENT

Auto Insurance Coverage: Yes No

Responsible Party=s Name:

Address:

Name of Insurer:

Agents Name/Address:

Attorney=s Name: Address: Phone #: ( )

FEMALE HEALTH HISTORY

MENSTRUAL HISTORY

LMP ~ Definite ~ Approximate (Month Known) ~ Unknown ~ Normal Amount/Duration

Menses Monthly ~ Yes ~ No Frequency: Q_____ days Menarche_______ (age onset) ~ Final___

Date of last pap_________ Normal or Abnormal

Date of last colposcopy__________ Findings_____________________________

Date of last mammogram__________ Normal or Abnormal

Number of sexual partners________ Are you sexually active with ~ males ~ females ~ both

Number of pregnancies________ Full-term________ Premature________

Miscarriages________ Terminations______ Stillbirths_______ Multiple Births_______

Adopted_______ Living_______

past pregnancies (last six)

date mo/yr

ga weeks

length of labor

birth weight

sex m/f

type delivery

anes.

place of delivery

preterm labor yes/no

comments/complications

Have you ever had any of the following:

Bacterial vaginosis Y N Vaginal Yeast Infections Y N

Gonorrhea Y N Genital Warts Y N

Abnormal Pap Y N (Human Papilloma Virus)

Pelvic Inflammatory Disease Y N Sexually Transmitted Disease Y N

Syphilis Y N Trichomonas Y N

Has/have your partner(s) ever had any of the above, received a blood transfusion, used illegal drugs or had multiple sexual partners? If yes, please explain______________________________________________________

____________________________________________________________

How often do you do self breast exam?____________________

PATIENT=S SIGNATURE______________________________________

PROVIDER=S SIGNATURE____________________________________

DATE__________________

MARSHALL WOMEN’S CARE PATIENT HEALTH HISTORY

PLEASE ANSWER THE FOLLOWING QUESTIONS TO THE BEST OF YOUR ABILITY

Name: Birth Date

Age Sex Marital Status_____ Occupation ____________________

PAST HEALTH HISTORY

Please list all previous hospitalizations, surgeries, injuries, and blood transfusions. Include dates, hospitals, and physicians.

_______________________________________________________________________

CURRENT HEALTH STATUS

ALLERGIES: _____________________________________________________________

Please Include Any Medications, Foods, Or Other Things To Which You Are Allergic

CURRENT MEDICATIONS: Please List all medication which you are currently taking.

(Be Sure To Include Over The Counter Contraceptives And Medications Taken Only Occasionally)

Name of Medication

Strength

How Often

Date Began

Date Last Taken

HAVE YOU EVER HAD ANY OF THE FOLLOWING?

HIGH BLOOD PRESSURE Y N BLEEDING DISORDER Y N

HEART DISEASE Y N THYROID DISORDER Y N

STROKE Y N LIVER DISEASE Y N

DIABETES Y N EPILEPSY/SEIZURES Y N

CANCER Y N ASTHMA Y N

LUNG DISEASE Y N KIDNEY DISEASE Y N

ULCERS Y N ALCOHOL/DRUG ADDICTION Y N

ARTHRITIS Y N ANXIETY Y N

HEADACHES Y N DEPRESSION Y N

ANEMIA (LOW IRON) Y N H. I. V. Y N

Please list other illnesses which you think would be important to your care.

_________________________________________________________________________

LIFE HABITS

#1 Do You Or Have You Ever Used Tobacco, In Any Form? Y N

Age Started Age Quit Type And Amount

#2 How Much Coffee, Tea, And/Or Soda Do You Drink In A Day?

#3 How Much Alcohol Do You Drink?

Daily Weekly Less Than 3/Month Never

#4 How Many Hours Of Sleep Do You Get Within A 24 Hour Period?______________________

Do You Generally Feel Rested? Y N

#5 What Type Of Exercise Do You Practice? Running Aerobics Walking

None Other__________________

#6 What Activities Do You Do For Fun?____________________________________________

#7 Former schooling __________________________________________________________

#8 Occupation_______________________________________________________________

FAMILY HEALTH HISTORY

To your knowledge, do any of your immediate family members have the following? If Yes WHO?

High Blood Pressure Bleeding Disorder

Stroke Liver Disease

Diabetes Epilepsy/Seizures

Cancer Asthma

Lung Disease Kidney Disease

Ulcers Alcohol/Drug Addiction

Heart Disease Thyroid Disorder

Arthritis Anxiety

Headaches Depression

Anemia (Low Iron) H. I. V.

PATIENT=S SIGNATURE DATE _______________________