NEW PATIENT REGISTRATION INFORMATION

Doctor you are here to see ______Date ______

Patient Name ______Age ______DOB ______

Nickname (What do you prefer to be called?) ______

Social Security No. ______- ______- ______Drivers License No. ______State ______

Address ______City ______State _____ Zip ______

Email Address ______Is it ok to communicate via email? ______

Phone (check preferred): [ ] Cell ______[ ] Home ______[ ] Work ______

Employer ______Occupation ______

Spouse/partner name ______DOB ______Phone ______

Insurance company ______

Member/ID No. ______Group No. ______

Primary Physician ______Phone ______

How did you hear about us? Physician referral Insurance Mailing Website/Internet Friend

Referred by Friend ______Other ______

Who should be notified in case of emergency?

Name ______Relationship ______Phone ______

YOUR PERSONAL HISTORY

Reason for today’s visit? ______

Relationship status: SINGLE MARRIED DIVORCED SEPARATED WIDOWED Other ______

ETHNICITY: Self ______Spouse ______

Are you still menstruating? ______First day of last menstrual cycle? ______Age at first period? ______

How often does your period occur? ______Average number of days bleeding? ____ Age of menopause? ____

Are your cycles regular? ______Flow (circle one) LIGHT NORMAL HEAVY

Are you currently pregnant? ______How many pregnancies in the past? ______

Number of: Live births ______Miscarriages ______Terminations ______

Are you sexually active? ______Have you been in the past? _____ Do you want STD testing today? ______

Date of last Pap smear ______Result ______Clinic/Doctor Name ______

Have you ever had an abnormal Pap Smear? ______If so, when?______

IF APPLICABLE: Date of last Mammogram ______Result______Facility performed______

Date of last Bone Density Scan/Result______Date of last Colonoscopy/Result ______

PAST MEDICAL HISTORY

YES / NO / CONDITION / YES / NO / CONDITION
Serious injury or accident / Irritable Bowel
Stroke / Cancer
Asthma / Bleeding disorder/ Blood disease
Diabetes / Migraine Headache
High Blood Pressure / Mental Illness
Elevated Cholesterol and/or Triglycerides / Depression/ Anxiety
Mitral Valve Prolapse / Skin Disorder
Heart Disease / Hepatitis
Seizures / Chicken Pox
Thyroid problems / Measles
Gallbladder/ Liver/ Kidney problems / Autoimmune Disease
Gastric Ulcers/ Colitis / Other medical illness

Please list all SURGERIES/HOSPITALIZATIONS:

1.  ______

2.  ______

3.  ______

4.  ______

Please list all MEDICINES:

1.  ______Dosage______Frequency ______

2.  ______Dosage______Frequency______

3.  ______Dosage______Frequency ______

4.  ______Dosage______Frequency ______

PREFERRED PHARMACY: ______Phone number: ______

OB/GYN HISTORY Please check if you have experienced the following:

Polycystic ovarian syndrome / Fibroids / Endometriosis
Abnormal pap smear / Genital Herpes / Frequent vaginal infections
Cryotherapy/LEEP / Sexually transmitted disease / Urinary incontinence
Painful menses / Ovarian Cysts / Infertility

PERSONAL LIFESTYLE HISTORY

YES / NO / EXPLAIN:
ALLERGY to any medication and reaction:
Currently smoke How many packs per day?
Drink caffeine daily
Drink alcohol or beer regularly How many drinks per day/week?
Perform regular self breast exams
Exercise: What kind? Duration? Days per week?
Current Supplements: Name of supplement & Dose

PAST FAMILY HISTORY:

Yes / No / CONDITION: Explain (if deceased please give ages and dates)
Stroke
Colon Cancer
Breast Cancer
Ovarian Cancer
Other Cancer
High Blood Pressure
Heart Disease/ Heart Attack
Mental Illness/ Emotional Disorder
Bleeding Disorder/ Blood Disease
Liver or Kidney Disease
Lung/ breathing problems
Neural Tube Defect/ Mental Retardation
Thyroid Disease
Autoimmune Disease
Other

Dr. Dian Ginsberg MD. FACOG :: Dr. Lauren U. Ta MD. FACOG :: Dr. Ginny Weathers MD. FACOG Page 1