Annual Update Form
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1ASSOCIATED GYNECOLOGY
ANNUAL UPDATE
Date:_______________
Name:____________________________________________________ Age______________________
Primary Care/Family Doctor:_________________________
Insurance________________________
Insurance Required Lab:
__Labcorp
__Quest
__LabOne
__ RENOWN
Other _______________
Required Radiology: (from insurance book)________________________________________________
ALLERGIES to medications:________________________________
Allergy to Latex?___________
MEDICATIONS: Include PRESCRIPTION, Nonprescription, herbal and vitamins:
_____________________________
______________________________
_____________________________
______________________________
_____________________________
______________________________
LAST MENSTRUAL PERIOD: _________________
Type of birth control?____________________
Reason for today’s visit:____________________________________________________
PAST HISTORY UPDATE: Any new illnesses, hospitalizations, or surgery since last visit?______________
_________________________________________________________________________________
FAMILY HISTORY UPDATE: Any new family history?___________________________________________
HABITS:
___TOBACCO _____Reg. Exercise
____ Take calcium
___Wear seatbelts
DATE OF: Last mammogram _______________
Last colonoscopy?________________
SYSTEM REVIEW: Please circle all that apply
GYN
None
Irreg. bleeding
Heavy periods
Cramping
Discharge
Itching
Burning
Bumps
Hot flushes
Night sweats
Vaginal dryness
Urinary
None
Incontinence
Frequency
Urgency
Blood in urine
Pain w/urination
Falling out feeling
Breast
None
Pain
Discharge
Lump
GI
None
Nausea/vomiting
Abd. Pain/cramping
Diarrhea
Constipation
Bloody stools
Other
None
Unexplained weight gain
Weight loss
Fatigue
Headaches
Other problems:
MEDICARE PATIENTS: MAY GET ANNUAL COVERAGE IF YOU HAVE THE FOLLOWING HIGH RISK FACTORS
(V15.89):
Please check those that apply
___Age of 1
st
intercourse before age 16 ___5 or more sexual partners ___History of STD: HPV etc
___Fewer than 3 paps in past 7 years
___Exposure to DES
FOR INSURANCE BILLING: I, the undersigned, assign directly to Associated Gynecology, all insurance benefits, if
any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges,
whether or not paid by insurance. I hereby authorize release of all information necessary to secure the payment of
benefits.
__________________________________________________
_______________________
Signature of Responsible Party
Date
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