Returning patient annual / Well woman Preventative Exam

Name:

Date:

Age:

Date of Birth:

Updated Demographics (address, phone number, name change, etc.)

Date of last menstrual period:

None due to:

Hysterectomy Menopausal Other

If other, specify:

How many days do you bleed:

How many days from one cycle to the next:

Any problems with your period?

Yes No

If yes, please explain

Are you currently sexually active?

Yes No

How many partners in the last 12 months?

Are you currently using a contraceptive?

Yes No

if yes, type:

IUD

Oral

Implant

Rhythm Method

Sterilization

Partner Vasectomy

Condoms

Other

Withdrawal

Do you smoke:

Yes No

If yes, type:

Cigarettes

E-Cigarettes

How long?

Do you drink alcohol?

Yes No Past

If yes, drinks

Per

Day Week Month

Do you use recreational drugs?

Yes No Past

What kind

Caffeine Intake Cups:

Per

Day Week Month

Do you exercise regularly??

Yes No

How many days per week?

What kind

Are you on a special diet/have you made any diet changes?

Yes No

Vegan

Vegetarian

Restrictions

Other

If Restrictions, specify:

If other, specify:

Have there been any events that have recently caused increased stress that need to be addressed?

Yes No

Would you like to explain

Are you wanting to be tested for Sexually Transmitted Diseases today?

Yes No

If so, which:

HPV

CHLAMYDIA

GONORRHEA

HIV

SYPHILIS

HEPATITS B

***deductibles or copay may apply to the laboratory when performing the test, Complete Women's Healthcare does not know your lab benefits***

Are you currently or have you ever been a victim of abuse or domestic abuse?

Yes No

Current Medications / Dosages

Add Medications

PREFERRED PHARMACY INFORMATION

Local:

Phone Number:

Mail in:

Phone Number:

Are you under the care of another Physician (Including primary care) for a medical condition?

Yes No

Primary Care Physician:

Practice Name:

Add Specialty Physician

WITHIN THE LAST YEAR HAVE YOU HAD

Any new medical conditions?

Any surgeries performed?

When Was Your Last

Pap Smear

Mammogram

Colonoscopy

Dexa/Bone Scan

Routine Labs

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Hereditary Cancer Risk Assessment Questionnaire - General Instructions

Please answer the following questions about your personal and family history to the best of your knowledge. This will help your provider understand if there could be patterns of hereditary cancer in your family. For personal history, enter the types of cancer you have had and your age at diagnosis. For family members who are blood relatives, enter the types of cancer they had and their approximate age at diagnosis. Family members include parents, siblings, children, uncles, aunts, grandparents, great-grandparents, grandchildren, great-grandchildren, great-uncles, great-aunts, nieces, nephews, or half-sibling.

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Please Fill in

Add new row

Please complete the following with your provider

Check all that apply:

that apply. Personal or family history of cancer at age 50 or younger

Personal or family history of ovarian or pancreatic cancer

Personal or family history of one or more of the following conditions: Male Breast Cancer / Triple Negative Breast cancer / 10 or more colorectal polyps

Two relatives with cancer on the same side of your family

Ashkenazi Jewish descent

You have had hereditary cancer genetic testing (if yes, please attach the report to the Empower Requisition Form)

Family member that has had hereditary cancer genetic testing. If yes, list gene mutations found, if any:

Concerned about personal and/or family history of cancer

Family member that has had hereditary cancer genetic testing. If yes, list gene mutations found, if any:

Signatures

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Name

Patient Signature

Date

Provider's Name

Provider's Signature

Date

WELL WOMAN CONSENT FORM

You have been scheduled to have a Well-Woman exam today. The annual well woman exam is an essential part of your ongoing health maintenance. Despite changes in recommendations for certain test such as the Pap test, a regular annual exam is strongly recommended. Most health insurance companies will cover most in full, if not all, of the charges associated with this type of visit. Please check with your insurance company to determine how your visit will be covered.

What things are normally considered to be part of the annual well-woman exam?

A clinical breast and pelvic exam, Pap smear but the frequency of these exams depends on your age, health, and risk factors for certain conditions.
Reproductive health concerns, birth control options, menstrual, menopause and sexual health
Breast cancer screening
Genetic screening for cancer for women with certain risk factors
Bone density screening
Screening for sexually transmitted infections (STI's)
Screening for depression, anxiety and other mental health problems

Any labs that are ordered for you today are billed separately by the lab company. The labs MAY or MAY NOT be covered by your insurance. Reminder you will received a separate invoice for the lab for any balance or test not covered by your insurance.

Important Note:

The intent of an annual well-woman visit is for routine health maintenance. The assumption is that you do not have any specific medical problems or conditions. If you discuss any problem-oriented issue with your provider (e.g., back pain, breast pain, rashes, sleeping problems, yeast infections, medication adjustments, requesting additional labs other than your preventative routine labs), your insurance may be billed separately and in addition to your well-woman visit since problem-oriented visits usually necessitate a visit. Please review your insurance coverage for more information on what is covered as part of your visit.

Please sign below when you have read and understood this form.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

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