Cole Family Practice, LLC - Registration Form- PREGNANCY

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Cole Family Practice, LLC - Registration Form- PREGNANCY Patient Information First: Middle: Last: Male Female Date of Birth: Marital Status: M S D W SS#: Address: City: State: Zip: Phone: (H) (C) (W) Email address: Emergency Contact: Phone: Employer Information: Patient s Employer: Occupation: Address: City: State: Zip: Parent or Financially Responsible Party (if different than patient) First: Middle: Last: Male Female Date of Birth: SS#: Address: City: State: Zip: Phone: (H) (C) (W) Relationship to Patient: Primary Insurance Insurance Name: Cardholder s Relationship to Patient: ID #: Co-Pay Amount: Secondary Insurance Insurance Name: Cardholder s Relationship to Patient: ID #: Co-Pay Amount: Please Present Insurance Cards and Picture ID at Reception Desk

Who referred you to Cole Family Practice? Have you received prenatal care prior to this appointment for this pregnancy No Yes, please specify. Father of the baby Name: Contact Number: If married, how long: FOB occupationemployer: Patient Medical, Surgical, Social & Family History List Medication Allergies: List all Current Medications (prescriptions, OTC, hormones, or herbal remedies) Pharmacy (Please list name and Street ): Patient Surgical History (List year of surgery) No History of Surgeries Appendix Removed Artificial Joints C-Section Pins or Plates inserted (location: ) D & C Spleen Removed Ear Tubes Thyroid Removed Gall Bladder Removed Tonsils Removed Hernia Pace Maker Other: Height: Weight: Pre-Pregnancy Weight: Patient Health History No History of Illness Health Maintenance: ADHD Autism Hearing Loss Date of last Complete Physical: Allergies (Seasonal) Heart Attack Date of last EKG: Arthritis Heart Burn (acid reflux) Date of last cholesterol screen: Asthma High Blood Pressure Date of last Bone Density: Bipolar High Cholesterol Date of last Tetanus Injection: Cancer (location? ) Date of last Colonoscopy: Congestive Heart Failure Interstitial Cystitis Date of last dental exam: COPD Emphysema Kidney Stones Date of last Mammogram: Crohn s Hypothyroid Hyperthyroid GYN Last Period: Sure No Yes Depression Anxiety Migraine Headaches Periods regular every 28-30 days? No Yes Diabetes Seizures Date of last Pap: Normal: No Yes Diverticulitis Stomach Ulcers How was your pregnancy Confirmed? Stroke Fibromyalgia Home Pregnancy test Doctor s Office #of Pregnancies: # Vaginal deliveries: # C-sec: # Miscarriages: # Abortions: How do you feel about this pregnancy? Happy Sad Unsure How do you want to feed your baby? Both unsure If your baby is a boy, do you want him circumcised? No Yes When you deliver your baby, what type of pain medicine do you want? Epidural IV Medication Nitrous Oxide None What type of birth control do you want to use after your baby is born? Oral Contraceptive Patch Nuva Ring Condoms Depo Provera IUD Tubal Ligation Unsure Implant Natural Family Planning

Pregnancy History Please include ALL pregnancies including any miscarriages, abortions, or preterm Pregnancy MonthYear Gestational Age Gender Infant weight Vaginal or Cesarean Pain Management Feeding or Bottole I Infant s Name Hours in Labor Details or Complications # 1 #2 #3 #4 #5 Patient and Family Medical History Please check any of the following that relate to YOU or YOUR FAMILY Multiple births (twins, triplets) Lung Disease GYN Problems (abnormal pap smears) Cancer Gastrointestinal problems Hematologic High Blood Pressure Disease Infertility & recurrent miscarriages Heart Disease Urinary Tract Problems History of sexual physical abusetrauma OperationsAccidents EndocrineMetabolic (DiabetesThyroid) Neurological STD, HPV, or Group B Strep Phlebitisvaricosities PsychiatricMental Illness ImmunologicalInfectious disease Other Please check any of the following that relate to YOU, FATHER of BABY and BOTH FAMILIES Patient s age > 34 at delivery Recurrent pregnancy loss (>2) andor still birth Other inherited or chromosomal disorder Thalessemia Other structural birth defect Neural Tube Defect Congenital Heart Defect Maternal metabolicendocrine disorder (Diabetes, PKU) Down syndrome Autism Tay Sachs Canavan Disease, Gauchers Hemophilia or other blood disorders Cystic Fibrosis Huntingtons Chorea You or baby s father had a child with a birth defect not listed above

Patient s Family Health History Father List any health problems: No Known Health Problems Has Died Age and Cause of Death: Mother List any health problems: No Known Health Problems Has Died Age and Cause of Death: Brothers How many No Known Health Problems List any health problems: Has Died Age and Cause of Death: Sisters How many No Known Health Problems List any health problems: Has Died Age and Cause of Death: Social History Marital Status: Married Single Divorced Widowed Patient s occupation Highest level of education completed: Did you have any special needs in school? No Yes How do you learn best? ListeningWatching Demonstration Reading Are you enrolled in any of the following programs? WIC Social Security AFDC Food Stamps Alcohol use? No Yes- Beer Liquor Wine Average amount - Day Week Month Year Smoke or Tobacco use? No Yes How many Packs per Day Smokeless Tobacco? Yes No Recreation Drug Use? No Yes, please list Caffeine (soda, tea, coffee )? No Yes Average amount Day Week Month Year Religious Preference: Any spiritualcultural needs that would affect how we care for you? No Yes Any objection to receiving blood products? No Yes Do you live in aan? House ApartmentCondo Where you live do you have: Electricity Water Cooking Facilities Stairs Form of transportation: Own a car Public FamilyFriends TennCare Do you have a living will, durable power of attorney, or advanced directives? No Yes If No, would you like information? No Yes

OFFICE POLICY I authorize Cole Family Practice, LLC to furnish information to insurance carriers concerning my care. I agree to pay Cole Family Practice, LLC for all services rendered to my dependents or myself. I understand that I am responsible for any amount not covered by my insurance. SELF-PAY PATIENTS will be required to pay for your office visit before you are seen. However, you are responsible for any additional cost related to the visit. Federal Law requires that we bill every patient the same amount. We are not allowed to change billing based on whether or not patients have insurance. INSURANCE PATIENTS IT IS YOUR RESPONSBILITY TO: Provide us with updated and current insurance information at each visit. Provide us with updated contact information including phone numbers and address. Pay your deductible andor copay at the time of service Pay for any services not covered by your insurance Make sure you have a current referral if your insurance requires one. As a courtesy to our patients we will file all claims with your insurance carrier and provide them with any information necessary to process the claim. YOU ARE RESPONSBILE FOR ALL SERVICES RENDERED IF (FOR ANY REASON) YOUR INSURANCE DOES NOT PAY- THE BALANCE IS YOUR RESPONSIBILITY. Unpaid Bills A collection agency will be chosen to manage delinquent accounts. Once referred to collections, no assistance will be provided by our office. If your account is placed with a collection agency, you will be responsible for all collections and attorney s fees necessary to collect this debt. CONSENT TO TREAT & MEDICAL RECORDS RELEASE AUTHORIZATION: I authorize Cole Family Practice practitioners to provide treatment that they may deem advisable for my dependents and me. I understand that these services are voluntary and I have the right to refuse these services. In the event of a life-threatening emergency, I consent for the provider to administer emergency treatment. I authorize Cole Family Practice to conduct urine drug screens as part of my assessment per the office policy. I authorize Cole Family Practice to obtain any previous medical records, for my dependents or myself, including lab and imaging results, if my providers feel it is necessary for the care of my dependents or me. I have read and understand the above items regarding insurance, finance, responsibility, authorization of charges, consent, and medical records and agree to the terms and conditions related to each item. Patient or Responsible Party Signature Date

Cole Family Practice, LLC HIPAAPermission From The Health Insurance Portability and Accountability Act (HIPAA) require Cole Family Practice to notify patients regarding how their Protected Health Information is handled. Our HIPAA policy is posted in the Lobby. You have the right to review policy and take a copy of the policy. With your permission, we may disclose your Protected Health Information to a family member, close friend, or any other person that you identify. I,, authorize Cole Family Practice to release any personal information relating to my health care To No One I have reviewed the HIPAA Notice of Privacy Practices for Cole Family Practice. I hereby acknowledge that I am familiar with and understand the terms of this policy. Print Patient Name: Patients Guardian Signature: Date:

Release of Medical Records Authorization Patient Name: DOB: Release records From: Cole Family Practice Release records to: West End Women s Health Center Main 615-936-5858 Fax 615-936-2600 ANDOR Vanderbilt Medical Center Labor & Delivery Main 615-332-2255 Fax 615-322-1170 I understand and give consent to release my prenatal record including but not limited to medical history, visit notes, medication lists, laboratory results, imaging reports, etc. I understand that my medical record may also include information on diagnosistreatment related to psychiatric or psychological conditions, drug andor alcohol abuse, acquired immune deficiency syndrome (AIDS), andor HIV status, andor sexually transmitted infections. I do do not authorize this information to be released. (Please initial) I understand no information may be disclosed by either agency to any individual or agency unless by written consent. I give my consent freely and voluntarily. Patient Signature Date I understand this authorization may be revoked in writing at any time, except to the extent that action has been taken in reliance on this authorization. Unless otherwise revoked, this authorization will expire 60 days after delivery.

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