Pre-visit Registration Form Date * MM/DD/YYYY Name * First Last * Last Email * DOB: * MM/DD/YYYY Age: * Address * Address Line 2 City * State * AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Postal Code * SS# * Referred By: * Home Phone: * Cell Phone * Race: * Ethnicity * Language * English Spanish French Italian Chinese Japanese Other Marital Status * Single Married Divorced Widowed Spouse's Name (If applicable): Spouse's Phone#: Person to Contact in Case of Emergency: * (Other than Spouse): Home Phone: * Cell Phone: * Relationship to Patient: * May we leave a voicemail if you are unavailable? Yes No May we contact you by postal mail? Yes No May we Contact you electronically by Email? Yes No Employment Information Employer Name: Occupation: Address: May we Contact you at work? Yes No Insurance Information Name of Insurance Company: * Policy Holder (if differenct than patient): Relationship: * Policy Holders DOB: * SS Number: * Policy No.: * Group No.: * Secondary Insurance: Policy Holder: Relationship: Policy Holders DOB: SS#: Policy #: Group #: Person Responsible for Payment: Patient Health History Reason for Visit: Allergies: Past Medical History: Please indicate YES if you have any of the following conditions: Diabetes: No Yes High Blod Pressure: No Yes Heart Disease: No Yes Thyroid Problems: No Yes Lung Problem: No Yes DES Exposure: No Yes Blod Clots: No Yes Gynecological History Date of Last PAP Smear: Abnormal PAP Smear: No Yes Colposcopy/Biopsy: No Yes Freezing LEEP: No Yes Sexually Transmitted Disease: No Yes Female/Sexual Problems: No Yes Breast Problems: No Yes Pregnancy History Pregnancy: No Yes Number of Pregnancies: 0 1 2 3 4 5 6 7 8 9 10 Number of Births: 0 1 2 3 4 5 6 7 8 9 10 Miscarriages/Abortions 0 1 2 3 4 5 6 7 8 9 10 Ectopics 0 1 2 3 4 5 Any Problems/C-Sections 0 1 2 3 4 5 Family History (Anyone in your family) Diabetes: No Yes Breast/Ovarian/Colon/Uterine Cancer: No Yes High Blood Pressure: No Yes Osteoporosis No Yes Heart Disease No Yes Birth Defects/Inherited Disease: No Yes Birth Control Current Method of Birth Control: Include vasectomy or tubualiagtion Have You Used the Pill? No Yes Have You Used an IUD? No Yes Are you satisfied with your current Birth Control? No Yes Women Having Periods Date of Last Period: Are your Periods Regular? No Yes Number of Days in your Cycle: (day one of your cycle to day one of the next) Length of your Cycle in Days: (start of cycle to end of cycle) On your heaviest day, how many Pads/Tampons do you use? Do you bleed between Periods? No Yes Do you have Cramps? None Mild Moderate Severe Do you Suffer from PMS? None Mild Moderate Severe Do you Bleed after Sexual Intercourse? No Yes Do you have Pain with Intercourse? No Yes For Everyone Age of Menopause: Date of Last Bleeding: Do you have Hot Flashes? No Yes How Often? How Old were you at the time of your First Period? Breast Health Do you Examine your own Breast Monthly? No Yes Any discharge/New Lumps in either Breast? No Yes When was your Last Mammogram? General Information Frequent Severe Headaches: No Yes Unusual Loss/Growth of Hair: No Yes Chest Pain/Shortness of Breathe/Mitral Valve Prolapse: No Yes Consitpation / Diarrhea: No Yes Bloody Stool / Black / Tarry Stools: No Yes Bladder Infections / Pain-Frequent Urinations: No Yes Do you Leak Urine? No Yes Recent Vaginal Itching / Discharge: No Yes Sexual Problems or Questions: No Yes Lost Weight Recently: No Yes Gained Weight Recently: No Yes Do you Exercise Regularly? No Yes Have you ever had a Drug Habit? No Yes Do you use Recreational Drugs? No Yes Do you use Alcohol? No Yes Do you Smoke? No Yes How Many Packs/Day? How Many Years ago? Hospitalization / Surgeries: (Please give dates and reasons) On a Scale of 1 - 10 (10 = Best), How would you rate your health? How did you hear about us? Electronic Signature (Please Read Carefully) * By typing my name in the above box I certify that the above information is true and correct to the best of my knowledge, and hereby authorize payment of medical benefits billed to my insurance to Progressive Women’s Healthcare, P.C. I hereby accept responsibility for payment for any service(s) provided to me that is not covered by my insurance. I also accept responsibility for fees that exceed the payment made by my insurance, if the practice does not participate with my insurance. I also agree to pay ALL co-payments, coinsurances, and deductibles at the time the service is rendered. I also authorize the practice to release any information required to process my claims.