Athens Women S Clinic, Llp

ATHENS WOMEN’S CLINIC, LLP

1270 PRINCE AVE, SUITE 201

ATHENS, GA 30606

(706) 548-1388

Patient’s Last Name: ______First: ______MI: ___

Address: ______Apt.#______

City:______State:______Zip:______

Home Phone# (______) ______Cell Phone# (______) ______

Social Security Number: ______Date of Birth (DOB): ______

Employer: ______Occupation: ______

Work Phone# (______) ______□ O.K. to call at work

Status: □ Minor □ Single □ Married □ Separated □ Divorced □ Widowed

If Married - Spouse’s Name:______Your Race: ______

Emergency Contact: ______Relation: ______Phone# (____) ______

Referring Physician: ______City:______

Primary Insurance: ______(BRING INSURANCE CARD TO BE SCANNED)

Holder’s Name: ______DOB: ____/_____/_____ Relation: ______

Policy Number: ______

Holder’s Mailing Address: ______Phone # (_____) ______

Secondary Insurance: ______(BRING INSURANCE CARD TO BE SCANNED)

Holder’s Name: ______DOB: ____/_____/_____ Relation:______

Policy Number: ______

Holder’s Mailing Address: ______Phone # (_____) ______

Athens Women's Clinic, LLP / New Patient Information Appointment Date: ______

Name: ______DOB: ______Age: ______

Race: ______Marital Status:  S  M  D  W ( Minor - under age 18)

Occupation: ______Place of business: ______

Cell Phone #: ______Preferred Lab for your insurance? ______

Preferred Pharmacy Name: ______Location of Pharmacy: ______

Family History: Cause of Death

Living Age Health & Age (if applies)

Mother Yes  No  ______

Father Yes  No  ______

Brother/Sister 1. Yes  No  ______

2. Yes  No  ______

3. Yes  No  ______

Husband Yes  No  ______

Children 1. Yes  No  ______

2. Yes  No  ______

3. Yes  No  ______

Family History of: List relationship & Maternal (mother’s side of family) or Paternal (father’s side of family) w/ details

For example: Grandmother-Paternal Breast Cancer

Relationship to you Details, if any

Cancer  Yes  No ______

Cholesterol  Yes  No ______

Diabetes  Yes  No ______

Epilepsy  Yes  No ______

Heart Trouble  Yes  No ______

High Blood Pressure  Yes  No ______

Hysterectomy  Yes  No ______

Kidney Trouble  Yes  No ______

Mental Illness  Yes  No ______

Stroke  Yes  No ______

Thyroid Problem  Yes  No ______

Tuberculosis  Yes  No ______

Do you use tobacco products? No  Yes  About ______cigarettes per day

Have you ever smoked? No  Yes  If so, how long & how much? ______

Do you drink alcohol? No  Yes  About ______drinks per week

Do you exercise? No  Yes  About ______hours a week; Kind ______

Do you wear your seatbelt? No  Yes 

Any history of an abusive relationship? If so, please explain: ______

List any allergies or drug sensitivities: ______

Outlook on life: ______Any family or marital concerns? ______

Any complaints? Please list: ______

How long have you had complaint(s): ______

Menstrual History

Age at first period: ______Are periods regular?  Yes  No Average # of days? ______

Periods are: Mild Moderate Heavy Cramps are: Mild Moderate Severe

Date of last period: ______Age of first intercourse: ______

Are you currently sexual active?  Yes  No

Form of birth control (if applies):______

Any menopausal symptoms? Please list: ______

Date of last pap smear: ______Results: ______

Have you ever had an abnormal pap smear?  Yes  No

If yes, give year & any procedures:______

Obstetrical History

List the date and outcome of all pregnancies, including miscarriages and abortions

Surgery and Hospitalizations History

List all surgeries and/or hospitalization

Current Medications: ______

______

______

______

Date of Last Mammogram: ______Results: ______

Have you ever had an abnormal mammogram?  Yes  No

If yes, give year & any procedures: ______

Do you do monthly breast exams?  Yes  No  Occasionally

Have you ever had a bone density?  Yes  No If so, list date: ______

Do you take calcium?  Yes  No If so, how much? ______

Have you ever had a colonoscopy or sigmoidoscopy?  Yes  No If so, list date: ______

If you have ever had any of the following, please check all that apply.

____ Accidents ____ Gonorrhea ____ Nervous breakdown

____ Anemia ____ Heart disease ____ Osteoporosis

____ Blood Transfusion ____ Heart murmur ____ Polio/meningitis

____ Cancer ____ Hepatitis ____ Pneumonia

____ Chicken pox ____ Herpes ____ Rheumatic fever

____ Chlamydia ____ High blood pressure ____ Scarlet fever

____ Colon polyp’s ____ HPV ____ Sickle cell

____ Condyloma ____ Infectious disease ____ Sleep problems

____ Diabetes ____ Jaundice ____ Stroke

____ Diphtheria ____ Kidney infections ____ Syphilis

____ Epilepsy/Seizure ____ Low blood pressure ____ Thyroid problem

____ Gallbladder disease ____ Migraine headache ____ Tuberculosis

____ German measles ____ Mumps

If you have ever had any of the following immunizations, please check all that apply.

____ Diphtheria /Pertussis(whooping cough) /Tetanus (lockjaw) ____ Tetanus /Diphtheria booster

____ Gardasil / HPV vaccine ____Shingles vaccine ____ Flu Shot ____ Pneumonia vaccines

Comprehensive Systems Review

If any of the following apply to you, please check and fill in date or blanks if appropriate.

Cardiovascular

____ Any chest pains

____ Racing heart/palpitations

____ Rheumatic fever

____ High blood pressure

____ Swelling

____ Dizziness/fainting

____ Blood clots in leg

____ Varicose veins

Ears

____ Problems hearing

____ Any discharge or pain

____ Any ringing in ears

Endocrine

____ Any thyroid problems

____ Increased sweating

____ Increased thirst/hunger

____ Increased urination

____ Heat/cold intolerance

Eyes

____ Eye Exam; Date: ______

____ Glasses or contacts

____ Glaucoma

____ Cataracts

____ Eyestrain, pain, redness or inflammation

____ Excessive tearing

____ Double vision and/or spots

Gastrointestinal

____ Nausea/vomiting

____ Changes in appetite or thirst

____ Vomiting up blood

____ Rectal bleeding

____ Change in bowel habits

____ Diarrhea/constipation

____ Indigestion

____ Food intolerance

____ Hemorrhoids

____ Jaundice

____ Flatus

General

____ Unusual recent weight changes

Details: ______

____ Any fever, weakness or fatigue

Head

____ Headaches

duration ______, severity ______

location ______

Hematologic

____ History of anemia

____ Easy bruising/bleeding

____ Past blood transfusions

Mouth / Throat

____ Dental Exam; Date: ______

____ Condition of teeth/gums

____ Any soreness/redness

____ Trouble swallowing

____ Any unusual/prolonged hoarseness

____ Bleeding gums

Musculoskeletal

____ Any joint pain/stiffness

____ Arthritis

____ Gout

____ Backache/muscle pain

____ Cramps, swelling or redness

____ Motor activity limitations

Please list any additional information or changes your physician should know about: ______

______

Neurological

____ Fainting/blackouts

____ Seizures

____ Paralysis

____ Tingling/tremors

____ Memory loss

Nose

____ Any nosebleeds

____ Frequent headaches

____ Nasal discharge or drip

____ Sinus pain

Psychological

____ Nervousness/moody

____ Insomnia

____ Headaches

____ Nightmares

____ Depression

____ Personality type

Respiratory

____ Any chest pains

____ Wheezing/coughing

____ Difficulty breathing or shortness of breath

____ Coughing up blood/sputum

____ Asthma/bronchitis

____ Emphysema/tuberculosis

____ Pneumonia/pleurisy

____ Chest x-ray; Date: ______

Skin

____ Any rashes, eruptions

____ Any dryness

____ Cyanosis/Jaundice

____ Any changes in skin, hair, nails

Urinary

____ Frequent/painful urination

____ Blood or pus in urine

____ Frequent urination at night

____ Incontinence

____ Urinary infections

______

______