Ob-Gyn Centre Of Excellence Patient Intake Form

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OB-GYN Centre of Excellence Patient Intake Form
For Office Use Only
Name: ___________________________________ Today’s Date: ________
BP: ______________ Height: _____________
Date of Birth:______________________________ Age: _______________
Pulse: ___________ Weight: _____________
Temp: ___________ LMP:________________
Primary Care Physician: ________________________________________
(Problems during a wellness exam are subject to an additional charge. This additional charge may result in a
Reason for Visit Today:
copay/coinsurance/deductible payment due. Some insurance companies require a separate visit for problems. You may be asked to return for the problem)
 Wellness Exam  Wellness Exam with Problems (Please List)_____________________________________________
 Other: ___________________________________________________________________________________________
Can we leave test/lab results or appointment information on your voice mail or answering machine?  Yes  No
Patient History
Allergies: __________________________________________________________________________________________
Pregnancy Prevention:  Pills  Condoms  Depo Provera  IUD  Nexplanon  Surgical Sterilization None
If birth control pills, list medication: _________________________________________________
Patient Medical History – Please check all that apply and list medication to treat condition:
Condition:
Medication(s) with dosage:
 Arthrits _____________________________ ____________________________________________________
 Asthma _____________________________ ____________________________________________________
 Bleeding tendency _____________________ ____________________________________________________
 Cancer ______________________________ ____________________________________________________
 Diabetes _____________________________ ____________________________________________________
 Depression/anxiety/mental illness _________ ____________________________________________________
 Heart trouble _________________________ ____________________________________________________
 Hepatitis ____________________________ ____________________________________________________
 HIV/AIDS ___________________________ ____________________________________________________
 High blood pressure ___________________ ____________________________________________________
 Hormone replacement therapy ___________ ____________________________________________________
 Stroke/deep vein thrombosis _____________ ____________________________________________________
 Seizures _____________________________ ____________________________________________________
 Sexually transmitted disease _____________ ____________________________________________________
 Thyroid disorder ______________________ ____________________________________________________
 Other______________________________ _ ____________________________________________________
 Other ______________________________ _ ____________________________________________________

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