New Patient Form – Female – Whole Woman Health

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New Patient Form – Femaleadmin2020-07-08T03:08:07+00:00

Step 1 of 4 - Basic Information

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Patient Name*
First M.I. Last
Address*
Street Address Address Line 2 City State ZIP Code
Today's Date*
MM slash DD slash YYYY
Date of Birth*
MM slash DD slash YYYY
Age*
Please enter a number from 1 to 100.
Marital Status*
Sex*
Email*
Place of Employment*
Home Phone
Cell Phone
Work Phone
How did you hear about our office?
Emergency Notification Name*
First Last
Emergency Notification Phone*
Emergency Notification Relationship*
Do you have the power of attorney for health care decisions?*
- Yes
- No

Responsible Party for Account
Primary Insurance
Secondary Insurance
Primary Holder
- Self
- Spouse
- Parent/Guardian
Sex*
Place of Employment*
Phone Number*
Consent to Treat:*
I hereby authorize the health care provider of Whole Woman Health to administer such treatment as they deem necessary. I realize that students may be involved in my care. I also certify that no guarantee or assurance has been made as to the results that may be obtained from the treatment.
Financial Responsibility:*
I agree that I am financially responsible for all charges for services rendered. I agree to pay all charges which are not covered by insurance or which are not promptly paid by the insurer. I understand and agree that it is my responsibility to obtain prior authorization required by my insurance company and to take all other steps to qualify for insurance coverage.
Release of Information:*
Please refer to the Notice of Privacy Practices and Consent to Release Information.
Signature:

Medical History Form
Date of last physical exam and pap smear:
MM slash DD slash YYYY
History of abnormal results:
Date of last mammogram:
MM slash DD slash YYYY
Date of last bone density test:
MM slash DD slash YYYY
Date of last blood lipids test:
MM slash DD slash YYYY
What are your immediate concerns today?*
Your Health History
Check all that apply to you.
- Heart
- Anemia
- Stroke
- Vascular Problems
- High Cholesterol
- High Blood Pressure
- Thyroid
- Dermatological/Skin
- Seizures
- Major Surgery
- Lung Problems
- Diabetes
- Bowel Problems
- Mental Illness
- Gall Bladder
- Eye Problems
- Cancer
- Depression
- Dizziness
- Numbness
- Joint/Bone
- Liver Disease
- Eating Disorder
- Arthritis
- Autoimmune
- Headaches
- Uterine Problems
- Breast Problems
- Abnormal Pap
- Ovarian Problems
- Pelvic Infections
- Allergies
- Herpes
- Neurological Problems
- Osteoporosis
- Fractures
- Kidney/UTI
- Other
Please explain above answers:*
Explain any allergies:
Explain any hospitalizations:
Family Health History
Check all that apply to your family history.
- Heart
- Anemia
- Stroke
- Vascular Problems
- High Cholesterol
- High Blood Pressure
- Thyroid
- Dermatological/Skin
- Seizures
- Major Surgery
- Lung Problems
- Diabetes
- Bowel Problems
- Mental Illness
- Gall Bladder
- Eye Problems
- Cancer
- Depression
- Dizziness
- Numbness
- Joint/Bone
- Liver Disease
- Eating Disorder
- Arthritis
- Autoimmune
- Headaches
- Uterine Problems
- Breast Problems
- Abnormal Pap
- Ovarian Problems
- Pelvic Infections
- Allergies
- Herpes
- Neurological Problems
- Osteoporosis
- Fractures
- Kidney/UTI
- Other
First day of last mensus:*
Number of days bleeding:*
Cycle length (typical # of days from 1st day of mensus to 1st day of next mensus):*
Age of first period:*
Heavy, painful, or irregular mensus:
Pregnancies (#):*
Births (#):*
Miscarriages (#):*
Vaginal deliveries (#):*
Cesarean deliveries (#):*
Complications:
Age of onset of menopause:

List Current Medications
List Current Supplements
List Current Herbs
Do you smoke?*
If so, how many cigarettes/cigars a week?
Do you consume alcoholic beverages?*
If so, how many a week?
Any recreational drug use?*
If so, how frequently?
Describe your exercise in a typical week:*
Describe your spiritual practices:*
Counseling, chiropractic, acupuncture, or other healthcare providers:*
Please describe 2 days typical food intake. Include water, alcohol and other beverages:
Day 1*
Day 1*
Day 1*
Day 1*
Day 2*
Day 2*
Day 2*
Day 2*
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Comments
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