SMG OB/GYN Lake Lansing St. Johns Returning Patient Questionnaire (Please print clearly and Fill out Entirely)

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Transcription:

SMG OB/GYN Lake Lansing St. Johns Returning Patient Questionnaire (Please print clearly and Fill out Entirely) Name: Former/ Maiden Name: Date of Birth: Age: Today s Date: *Language: Race: Ethnicity: *Do you have any barriers to communication? (please circle) Yes No Please List: Reason for today s visit? Primary Care provider? Preferred pharmacy? *Many questions are required by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Thank You. Advanced Directives *Do you have a Durable Medical Power of Attorney? (please circle) Yes No If no, would you like an information packet today? (please circle) Yes No Since your last visit have you had a change in any of the following? (please fill out only those that apply) Medications? Allergies? Medical conditions or surgeries? Family medical history? Personal and Social History: Please tell us about yourself. This information is intended to help us understand and meet the varied needs of the women we care for. How is your general health? ( ) Good ( ) Fair ( ) Poor Do you have regular dental check ups? Do you have any hearing problems? Do you have your vision check regularly? Are you immunizations up to date? Do you eat a healthy diet? Do you have any weight concerns? Do you exercise regularly? Do you use seat belts? ( ) Yes ( ) No *Do you do a monthly self breast exam? Do you take calcium/ vitamin D? Page 1 of 4 6/2017

Name: Date of Birth: Today s Date: Have you ever smoked cigarettes? Do you still smoke? Amount per day? If no, what year did you quit? If yes, how long have you smoked? Do you use smokeless tobacco? Do you drink alcohol? ( ) In recovery Are you interested in quiting? If yes, amount per week? Type (ex. Wine, beer, liquor, etc.): Are you interested in quitting? Do you use recreational drugs? ( ) In recovery How Often? Last use? Type (Marijuana, cocaine, meth, etc.): Are you interested in quitting? Have you ever been sexually active? Are you currently sexually active? Birth control? Type: If yes, partner(s) are: ( ) Male ( )Female ( ) Both *Have you ever been verbally, emotionally, physically, or sexually abused? Are you currently being verbally, emotionally, physically, or sexually abused? Do you feel safe in your home? Do you feel safe in your relationship(s)? *Marital Status: ( ) Married ( ) Separated ( ) Unmarried / Single ( ) Divorced ( ) Widowed ( ) Other: Living arrangements (ex. Alone, with spouse, children, etc.): Are you employed? If yes, where? Type of work: *Highest level of education completed? *Whst is your best learning method? ( ) Verbal ( ) Written ( ) Visual Menstrual History: Age of first period? My periods are: Please check all that apply Last menstrual period began? ( ) Regular ( ) Irregular ( ) Normal ( ) Heavy ( ) Painful ( ) Manageable / Tolerable ( ) Unmanageable, I want to talk about options for treatment Other Problems (Please List): Page 2 of 4 6/2017

Name: Date of Birth: Today s Date: Post- menopausal Women: Please check all that apply ( ) I have gone through menopause with no bleeding in the last year ( ) I have experienced some vaginal bleeding or spotting in the last year ( ) I am on hormone replacement therapy. List Type: ( ) I have taken hormones in the past and quit in (year): ( ) I am having trouble with hot flashes or night sweats and want to talk about treatment ( ) I have recently been experiencing a diminished sex drive ( ) Not applicable Contraception: Please check any that apply ( ) IUD ( ) Tubal Ligation ( ) Partner had vasectomy ( ) Birth control Pill ( ) Patch, ring or implant ( ) Condoms ( ) None ( ) Other ( ) Natural Family Planning Page 3 of 4 6/2017

Name: Date of Birth: Today s Date: Review of Systems: Have you been experiencing any of the following problems? ( ) No Problems General ( ) Chills ( ) Fatigue ( ) Fever ( ) Hot flashes ( ) Night Sweats ( ) Sleep disturbance ( ) Recent weight loss pounds ( ) Recent weight gain pounds Head, Eyes, Ears, Nose, and Throat ( ) Ear pain ( ) Hearing Loss ( ) Ringing in ears ( ) Congestion ( ) Nasal discharge ( ) Nosebleeds ( ) Sore throat ( ) Dental problems ( ) Vision problems Respiratory ( ) Shortness of breath ( ) Wheezing ( ) Cough Cardiovascular ( ) Chest pain ( ) Swelling ( ) Irregular heartbeat ( ) Heart palpitations ( ) Rapid heart rate Gastrointestinal ( ) Abdominal pain ( ) Bloody stools ( ) Constipation ( ) Diarrhea ( ) Nausea ( ) Vomiting Gynecology ( ) Pelvic pain ( ) Painful intercourse ( ) Vaginal discharge ( ) Painful periods ( ) Abnormal vaginal bleeding ( ) Nipple discharge ( ) Vulvar Itching ( ) Breast lump ( ) Genital ulcers ( ) Breast Pain ( ) Urinary frequency ( ) Painful urination ( ) Leaking Urine ( ) Nocturia (night urination) ( ) Urinary urgency Musculoskeletal ( ) Joint pain ( ) Joint stiffness ( ) Joint swelling ( ) Muscle pain ( ) Muscle weakness ( ) Limb pain / swelling Dermatological ( ) Acne ( ) Skin rash ( ) Mole changes ( ) Skin lesion Neurological ( ) Dizziness ( ) Headaches ( ) Numbness or tingling ( ) Weakness Psychological ( ) Anxiety ( ) Depression ( ) Decreased libido Page 4 of 4 6/2017

Missed Appointment Policy SMG OB/GYN Lake Lansing & St. Johns In order to provide quality care to our Patients, improve access, and minimize wait time, our office has adopted the following policy regarding missed appointments. I understand that if I should fail to keep a scheduled appointment three (3) times in twelve (12) consecutive months, it will be necessary for me to make arrangements to receive my medical care elsewhere. I further understand that the policy works as follows: A telephone call to cancel the appointment is required the business day prior to the scheduled appointment to avoid a missed appointment fee. If one appointment is missed, a reminder letter will be sent indicating that a scheduled appointment has been missed. If a second appointment is missed, another reminder letter will be sent, and a $25 fee will be generated. Upon failing to keep a third scheduled appointment, a certified letter will be sent indicating that three (3) scheduled appointments have been missed. A $50 fee will be generated. Within thirty (30) days, I will no longer be able to receive care at SMG OB/GYN Lake Lansing and will need to make arrangements to receive medical care from another source. I further understand that SMG OB/GYN Lake Lansing will assist me in finding another Physician through referrals, but that effective thirty (30) days from the date of the certified letter and with my primary Physician s consent, I will be removed from the active Patient list of SMG OB/GYN Lake Lansing. Please Note: Parents and/or legal guardians will be held responsible for the appointments of minor children. The current fee for a missed appointment is $25 to $80. Your insurance company will not cover this fee. You will not be able to be seen without payment of this fee. I have read the above policy in its entirety and fully understand that the above information relates to me and to my family members. Patient Signature Patient Name (Printed) Date Date of Birth

Release of Medical Information Consent Form SMG OB/GYN Lake Lansing and St. Johns may release any medical information to the following person(s). If there are no names written in this section we WILL NOT be able to release any information to anyone other than you. Name Relationship Name Relationship Name Relationship I do not want to list anyone to call on my behalf * * * * * * * * NOTE: A SIGNATURE IS REQUIRED BELOW EVEN IF NO ONE IS LISTED ABOVE Patient name (Please Print) Date of Birth Patient s Signature Date

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