New Patient Form

Patient Information

Full Name:

Former Last Name:

Preferred Name:

Social Security:

DOB:

Street Address

City

State / Province

Postal / Zip Code

Home #:

Cell #:

Work #:

Consent to SMS (text messages):

Yes No

Contact Preference:

Patient Email:

Consent to Email:

Yes No

How did you hear about us:

Patient Care Summary:

Yes No

Language:

Race:

Ethnicity:

Pharmacy:

Provider:

Guarantor (Responsible Party)

Self Other than patient Relationship to patient

Full Name:

DOB:

Mailing Address: (if different from patient)

Street Address

City

State / Province

Postal / Zip Code

Emergency Contact

Name:

Home #:

Cell #:

Relationship:

Insurance

Primary Insurance

Insurance Company:

Claims Address:

ID:

Group:

Copay:

Coinsurance:

Policy Holder Information:

Name:

DOB:

Relationship to Patient:

Secondary Insurance

Insurance Company:

Claims Address:

ID:

Group:

Copay:

Coinsurance:

Policy Holder Information:

Name:

DOB:

Relationship to Patient:

REMINDER

We would like to welcome you as a patient to Midland Women's Clinic. This form you are completing now will assist us in providing you with the best possible care. The scheduling and financial process can take up to 3-5 business days after receipt of this form. An additional email will be sent to you regarding your financial responsibility and estimation that will require a signature prior to your New OB appointment.
All patients and attending parties must arrive 10 minutes before their appointment. If you are late, you could be re-scheduled or moved to a different time. Visits that involve Sonograms will not wait for other parties to arrive.
Payment is required at check in. Your payment amount is based off of your benefits. Your appointment will be rescheduled if payment is not collected.
If you need tocancel orre-schedule your appointment, please call the office atleast 24 hours prior to your appointment toavoid being billed a $50.00 no-show fee.
We do not file Medicaid as a Primary or Secondary insurance carrier. Failure to present the correct insurance information claim denials and inaccurate calculation of payments due.

If you have any questions, please do not hesitate to call (432-699-2370 ext 205).
We look forward to starting your OB care with you!!

NEW OB FORM

Name:

Date of Birth:

First Day of Last Period:

On birth control?

How old were you when you first began menstruating?

Are they predictable?

How often?

Length of flow?

(days)

Date of Pregnancy test

Pregnancy weight

Father of the baby's name

Have you had any vaginal spotting with this pregnancy?

Yes No

Have you had any nausea/vomiting?

Yes No

Date of last Pap smear:

Doctor who performed Pap smear:

Medications currently taking:

Drug Allergies:

OBSTETRIC HISTORY

Total # Pregnancies

Number

Full Term

Number

Premature (< 37 weeks)

Number

Abortions

Number

Living Children

Number

Miscarriages

Number

Please List Each Pregnancy Below:

First Pregnancy

No. Date

Sex

Weight

Weeks Pregnant

Anesthesia (Epidural)

Type of Delivery

(Vaginal/C-Section)

Complications

Second Pregnancy

No. Date

Sex

Weight

Weeks Pregnant

Anesthesia (Epidural)

Type of Delivery

(Vaginal/C-Section)

Complications

Third Pregnancy

No. Date

Sex

Weight

Weeks Pregnant

Anesthesia (Epidural)

Type of Delivery

(Vaginal/C-Section)

Complications

Have you/or the father of the baby been exposed to HIV, Herpes, or Tuberculosis?

Have you been sick or had a rash since your last period?

Have you/or the father of the baby ever had an STD?

Yes No

If yes, please explain:

If you have had any surgeries before, please describe below:

Date & Type of Surgeries

PERSONAL MEDICAL HISTORY

History

Seasonal, Food, Environmental Allergies

Yes No

Anemia

Yes No

Asthma

Yes No

Autoimmune Disorders

Yes No

Infertility

Yes No

Breast Disorders

Yes No

Psychiatric Disorder

Yes No

Diabetes

Yes No

Heart Disease

Yes No

Hypertension

Yes No

Liver Problems

Yes No

Blood Transfusions

Yes No

Kidney Problems

Yes No

Thyroid Problems

Yes No

Abuse, molested, raped, or assaulted

Yes No

Uterine Abnormalities

Yes No

Blood Clots

Yes No

Abnormal Pap Smears

Yes No

Neurologic Problems

Yes No

Depression

Yes No

Do you have cats at home?

Yes No

Have you had the Chicken Pox?

Yes No

Is the father of the baby in good health?

Yes No

Do you drink alcohol?

Yes No

Amount per week?

Do you smoke?

Yes No

Amount per week?

How many years?

Has anyone in your family or the father of the baby’s family had any of these?

Disorder

Spina Bifida

Yes No

If yes, who?

Down Syndrome

Yes No

If yes, who?

Congenital Heart Defects

Yes No

If yes, who?

Cystic Fibrosis

Yes No

If yes, who?

Tay-Sachs

Yes No

If yes, who?

Thalassemia

Yes No

If yes, who?

Canavan Syndrome

Yes No

If yes, who?

Huntington's Chore

Yes No

If yes, who?

Autism

Yes No

If yes, who?

Mental Retardation

Yes No

If yes, who?

Muscular Dystrophy

Yes No

If yes, who?

Sickle cell disease/trait

Yes No

If yes, who?

Type 1 Diabetes/PKU

Yes No

If yes, who?

Recurrent Pregnancy Loss/Stillbirth

Yes No

If yes, who?

Hemophilia/Blood Disorder

Yes No

If yes, who?

Other Genetic Screening/Birth Defects

Yes No

If yes, who?

NEW PATIENT FORM

Name:

Social Security:

DOB:

Street Address

Apt/Unit:

City

State / Province

Postal / Zip Code

Home #:

Cell #:

Consent to SMS (text messages):

Yes No

Patient Email:

Consent to Email:

Yes No

Patient Care Summary:

Portal Paper

Language:

Provider:

Guarantor (Responsible Party - Only if patient is minor)

Self Other than patient Relationship to patient

Name:

DOB:

Emergency Contact

Name:

Home #:

Cell #:

Relationship:

Insurance

Primary Insurance

Insurance Company:

Claims Address:

ID:

Group:

Policy Holder Information:

Self

Name:

DOB:

Relationship to Patient:

Secondary Insurance

None

Insurance Company:

Claims Address:

ID:

Group:

Copay:

Coinsurance:

Policy Holder Information:

Name:

DOB:

Relationship to Patient:

Please check all that apply:

Systematic symptoms

Weight change

Chills

Fever

Night sweats

Fatigue

Head symptoms

Headache

Facial pain

Sinus pain

Eye symptoms

Eyesight problems

Light sensitivity

Eye pain

Eye itching

Ears/ mouth/throat symptoms

Earache

Hearing loss

Ringing in ears

Nosebleeds

Nasal discharge

Mouth sores

Bleeding gums

Hoarseness

Throat pain

Neck symptoms

Neck pain

Neck stiffness

Swelling in the neck

Breast symptoms

Breast pain

Nipple discharge

Breast lump

Cardiovascular symptoms

Chest pain

Fast heart beat

Palpitations

Pulmonary symptoms

Shortness of breath

Cough

Coughing up blood

Wheezing

GI symptoms

Change in appetite

Difficulty swallowing

Heartburn

Nausea

Vomiting

Nausea

Vomiting

Blood in bowel movements

Genitourinary symptoms

Burning with urination

Frequent urination

Blood in urine

Genital lesions

Skin symptoms

Itching

Skin lesions

Rashes

Endocrine symptoms

Excessive sweating

Excessive thirst

Change in libido

Musculoskeletal symptoms

Joint pain

Joint stiffness

MuscIe aches

Neurological symptoms

Dizziness

Vertigo

Fainting

Weakness

Numbness

Other symptoms

Trouble sleeping

Anxiety

Depress ion

Comment:

Name

Day Phone

Please enter a valid phone number.

Date of Birth

Last menstrual period

Primary Provider:

History and Physical

Surgical Procedures & Dates

Current Medication & Dosage

Default Pharmacy

Phone Number

Please enter a valid phone number.

Address

Allergies/ Adverse Reactions

Drug/Allergen Reaction

Personal History:

Cancer History

Yes No

Please List Type & Describe

Cardiac History (Heart)

Yes No

Please List Type & Describe

Endocrinology History (Diabetes, Osteoporosis, Thyroid etc.)

Yes No

Please List Type & Describe

Gastrointestinal History (Crohn's, gallbladder, hemorrhoids, liver etc.)

Yes No

Please List Type & Describe

Hematology History (Bleeding disorders)

Yes No

Please List Type & Describe

Neurology History (Headaches, seizures, strokes etc.)

Yes No

Please List Type & Describe

Psychological History (Anxiety, Bipolar, Depression etc.)

Yes No

Please List Type & Describe

Pulmonary (lung)/Rheumatology/Urology

Yes No

Please List Type & Describe

Social History

Do you drink alcohol?

Yes No

If so, how many drinks per week

Wine Beer Other

Tobacco years of use

Packs per day

Family history Relation (Breast, Cervical, Colon etc.) Onset Age Died Maternal/Paternal

Gynecological History

Last Mammogram

Date & Notes

Last Colonoscopy

Date & Notes

Last DXA (Bone Scan)

Date & Notes

Last Pelvic ultrasound

Date & Notes

Last Pap Smear

Date & Notes

Last HPV test

Date & Notes

HPV Vaccination

Date & Notes

History of Abnormal PAP

Date & Notes

History of Cervical Dysplasia

Date & Notes

Are you sexually active?

Yes No

Current birth control method

How old were you when you began menstruating?

How old were you when you began menopause?

Post menopause hormonal use?

History of endometriosis

History of fibroids

History of infertility

History of ovarian problems

History of PCOS

Past Pregnancies

Write down all

Delivery, Gestation, Weight, Sex, Delivery Type and Anesthesia

How many total pregnancies have you had?

How many were born premature?

How many were miscarriages?

How many were abortions?

Have you had any complications with your pregnancies? Explain:

Anything else you would like to discuss?

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