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New Patient Form – Female
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2020-07-08T03:08:07-05:00
Step
1
of
5
- Basic Information
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This field is for validation purposes and should be left unchanged.
Patient Name
*
First
M.I.
Last
Address
*
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
*
Married
Single
Sex
*
Male
Female
Prefer not to answer
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
*
Male
Female
Prefer not to disclose
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
Please explain above answers:
*
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?
*
Yes
No
If so, how many cigarettes/cigars a week?
Do you consume alcoholic beverages?
*
Yes
No
If so, how many a week?
Any recreational drug use?
*
Yes
No
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
*
Cancellation Policy: At Whole Woman Health, we look forward to treating our patients with the highest care possible. Due to the high demand of patients waiting to be seen, those who cancel their appointment with less than 24 hours notice will be charged 50% of the cost of the services that would have been rendered.
*
I understand the cancellation policy and authorize Whole Woman Health to charge the card on file as needed for payment on services cancelled with less than a 24 hour notice.
I understand that my information will be saved to file for future transactions on my account and authorization will remain in effect until I formally request cancellation.
Card Type:
*
Master Card
Visa
Discover
American Express
Credit Card Number
*
Expiration Date
*
Format as month and year with no space or backslash ex. 0124 or 012024
CCV
*
Billing Zip Code
*
Signature
*
Please type full name here
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