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
Date / # of weeks / Birth Weight / Type of Delivery / Preterm(Y/N) / Sex / Comments/
Complications
Surgery and Hospitalizations History
List all surgeries and/or hospitalization
Surgery / Reason for Hospitalization / DateCurrent 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
______
______