Patient Demographic Form

Patient Demographic Form

Date:

Referring Doctor/Office:

Personal Contact

Name: Maiden Name: Home Address: Home Phone: Occupation:

Date of Birth:

Social Sec #:

City:

State:

Zip:

Cell Phone:

Email:

Employer:

Work #:

Emergency Contact

Emergency Contact Name: Relationship: Contact Phone #:

Insurance

Primary Insurance Company: Subscriber Name:

Policy #: Relationship to subscriber:

Group#:

Subscriber's Social Sec #:

Date of birth:

CHECK HERE IF YOU HAVE SECONDARY INSURANCE

Secondary Insurance Company: Subscriber Name: Subscriber Social Sec #:

Policy #:

Group #:

Relationship to subscriber:

Date of birth:

PERSONAL: Name Current Age Ethnicity/Race

PATIENT

SPOUSE/PARTNER

MEDICAL HISTORY (PATIENT): Select Yes or No

Do you have a history of any of the following?

Yes

No

Anemia

Anxiety

Bipolar

Blood Clot in the Legs or Lungs

Blood Transfusion

Cancer

Depression

Diabetes

Any Heart Disease/Heart Attack

High Blood Pressure Infectious Disease (Hepatitis, HIV, Tuberculosis, etc)

Inflammatory Bowel Disease

Kidney Disease

Lung Disease (Asthma, COPD, etc.)

Lupus/Autoimmune Disorder

Migraines

Seizure Disorder/Epilepsy

Stroke

Thyroid Disorder (Hypo or Hyper) Other:

SURGICAL HISTORY (PATIENT): Select Yes or No

Have you had any of the following surgeries? Appendectomy Gastric Bypass Surgery Brain Surgery Breast Surgery Colon/Bowel Surgery Cosmetic Surgery C-Section D & C Gallbladder Removal Heart Surgery Hernia Repair Laparoscopy Spine Surgery Tonsils/Adenoid Removal Uterine or Ovarian Surgery Other:

Yes

No

GYNECOLOGIC HISTORY: Select Yes or No

Do you have a history of any of the following?

Yes

No

Abnormal Pap Smear/HPV

LEEP Procedure

Infertility/PCOS

Genital Herpes Sexually Transmitted Diseases: Chlamydia, Gonorrhea, Syphilis Other

Patient Name:

Patient History Page 1/4

OBSTETRICAL HISTORY: When was the first day of your last menstrual period? Are you sure of this date? How many times have you been pregnant? Is this pregnancy a result of infertility treatment? Have you ever had a miscarriage? If so, how many? Have you ever terminated a pregnancy?

Pregnancy Delivery Date #

Type of Delivery

How many weeks at time of delivery?

Baby's Weight

At Birth

Male or Female

1

2

3

4

5

Any Complications?

CURRENT PREGNANCY

During the pregnancy have you had a rash or fever of 103? or higher? Have you experienced any difficulty with the pregnancy for which you have sought medical attention (MD Office, ER, Urgent Care) such as bleeding, leaking fluid, or intense cramping? Have you had any x-rays during this pregnancy? Have you been exposed to any toxic substances that you know of during this pregnancy? Have you traveled outside the United States in the previous year? Do you have outdoor cats? Do you garden without gloves? Do you have any special concerns you want addressed today?

Patient Name:

Patient History Page 2/4

YES NO

Do you have any allergies to medications? If so, what are you allergic to? What type of reaction do you have?

Preferred Pharmacy Name & Phone Number:

MEDICATIONS: List all medications taken SINCE YOUR LAST MENSTRUAL PERIOD including over the counter medications & supplements

Medication:

Dosage:

Medication:

Dosage:

Medication:

Dosage:

Medication:

Dosage:

SOCIAL HISTORY:

Marital Status:

Married

Single

Tobacco Use:

No

Yes

Former (Year Quit?

)

Type: Cigarettes Other

Amount / day: __________ #Years: _______

Alcohol Use:

No Yes

Not During Pregnancy

Illicit Drug Use: No

Yes

Former (Year Quit?

Type: Marijuana Methamphetamines Heroin

Cocaine

) Prescription

IV Drug Use

FAMILY HISTORY: (Patient)

Please list any medical conditions such as diabetes, high blood pressure, cancer, stroke, thyroid disease, seizures, blood clotting problem or anesthetic complications in your family.

Is your mother alive or deceased? Is your father alive or deceased?

Age ____________ Age ____________

___________________________________ ___________________________________

Patient Name:

Patient History Page 3/4

Family Genetic History

1. Have you or has anyone in your family ever had/been diagnosed with:

PATIENT & FAMILY

FATHER of the BABY

& FAMILY

YES NO UNK YES NO UNK

FAMILY MEMBER RELATIONSHIP

(child, sibling, parent, aunt/uncle, cousin, grandparent)

a. Spina bifida, myelomeningocele, or anencephaly (neural tube defects)?

b. Heart defect at birth?

c. Other birth defect? (club foot, cleft lip or palate, gastroschisis, etc.)

d. Down syndrome?

e. Muscular dystrophy?

f. Huntington's disease?

g. Hemophilia (bleeding disorder)?

h. Blindness or deafness?

i. Other inherited chromosomal/genetic conditions?

j. Seen a genetic counselor or had genetic testing?

k. Intellectual disability, learning disability, or autism spectrum disorder?

If yes, was the person tested for Fragile X syndrome?

l. Mental illness?

m. A history of multiple miscarriages (two or more)?

n. A history of a stillborn baby or infant death?

2. Are you or anyone in your family of:

YES NO UNK YES NO UNK

o. African ancestry?

Sickle cell disease or trait?

p. A carrier for cystic fibrosis?

q. Italian, Greek, Mediterranean, or Asian ancestry?

A carrier for Thalassemia (Cooley's Anemia)?

r. Ashkenazi Jewish or French Canadian ancestry?

A carrier for Tay Sachs disease?

s. Is there a history of interfamily marriages or relationships?

Are you and your partner related by blood, such as cousins?

Patient Name:

Patient History Page 4/4

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