Patient
Patient Demographic Registration, The Women’s CenterDr. James J. Bendell MD, PhD (706) 845-0500Name: ________________________________ Date of Birth: ___/___/___ Age: ____ SSN: _____________ Date:______________Email Address(s): ______________________________ Street Address: _____________________________________City: ________ State: ___ ZIP: _______ Phone# (circle best # to call): Home: (____) __________ Work: (____) __________ Cell: (____) ___________ Emergency Contact: __________________________ Relationship: _________________ Emergency Contact #: (____) ___________Occupation/Position: ____________________________________________________ Student: Y / N (if yes FULL or PART TIME)Employer: _____________________________________________ Years: ______ Employer Phone: (____) __________ ext: _______Marital Status:_________ Spouse’s Name: __________________ Spouse’s SSN: ___________ Spouse’s Date of Birth: ___/___/___ Spouse’s Cell #: (____)_________ Spouse’s Work #: (____)_________ Spouse’s Employer: ________________________________ Primary Insurance Company: _____________________________________________ Insured’s Name: ______________________Insured’s Date of Birth: ___/___/___ Insured’s SSN: ________________ Relationship to Insured: ____________________________Secondary Insurance Company_____________________________________________ Insured’s Name: _____________________Insured’s Date of Birth: ___/___/___ Insured’s SSN: ________________ Relationship to Insured: ____________________________Medical and Personal HistoryWho referred you to our office? ________________________________________________________________________________Are you here for an annual exam, pregnancy or problem visit (please circle answer) First Day of Last Period: ____/____/___ When was your last: Pap: ___/___/___ Mammogram: ___/___/___ Dexa Scan: ___/___/___ Full Blood Screen: ___/___/___Tobacco Products: ______/day Alcohol: _____/day Do you think your weight is appropriate for your height? Yes: ___ No ____What brings you to the office (concerns, problems): _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Any Known Allergies (food, medication, environmental or latex)? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Current Medications: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Previous Surgeries (year): __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Medical Conditions: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Current Doctors and Their Specialty_________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________Patient Demographic Registration, The Women’s CenterDr. James J. Bendell MD, PhD (706) 845-0500Name: _________________________________ Age: ________ Chart #: _________________ Date: ________________ Birth Control1. Do you plan to have children in the future? Yes__ No__2. Current method of birth control? ______________________________________________________________3. How long Used: ______________________________________________________________Heavy Bleeding/Pain1. Do you ever experience pelvic pain that interferes with your normal activities?Yes__ No__2. Have you missed work or school because of your period? Yes__ No__3. Do have irregular or inconsistent bleeding? Yes__ No__4. Are your periods painful? Yes__ No__5. For how many days does your average period last? ___________ 6. How would you describe your periods: Light______ Medium______ Heavy______ Very Heavy _____MENOPAUSE1. Any menopausal symptoms (hot flashes, mood swings, vaginal dryness/pain)?Yes__ No__BLADDER and BOWEL FUNCTION1. Have you experienced unwanted leakage of urine?Yes__ No__2. Do you ever feel a sudden and immediate urge to urinate?Yes__ No__3. Do you use pads or other forms of protection to absorb bladder leakage?Yes__ No__4. Do you experience vaginal pressure or bulging, especially after standing?Yes__ No__5. Are you sometimes unable to control passing gas?Yes__ No__6. Are you sometimes unable to control passing stool?Yes__ No__7. Do you ever push on the back of your vagina to have a bowel movement?Yes__ No__SEXUAL FUNCTION1. Is sexual intercourse ever painful for you?Yes__ No__2. Has your desire for sex or enjoyment of sex changed?Yes__ No__Hereditary Cancer Risk ScreenPlease mark below if there is a personal or family history of any of the following cancers. If yes, then indicate family relationship and age at diagnosis in the appropriate column. Consider parents, children, brothers, sisters, grandparents, aunts, uncles, and cousin. Answer each statement individually – it is OK to end up listing the same cancer (or individual) more than once.Relationship Age at DiagnosisBreast Cancer before age 50 _______________________________________ _______________Ovarian Cancer _______________________________________ _______________Breast Cancer both breasts _______________________________________ _______________Breast and Ovarian Cancer _______________________________________ _______________Male Breast Cancer _______________________________________ _______________Ashkenazi ancestry _______________________________________ _______________Uterine Cancer before age 50 _______________________________________ _______________Colorectal Cancer before age 50 _______________________________________ _______________Uterine and Colorectal Cancer _______________________________________ _______________Uterine and/or Colorectal cancer AND _______________________________________ _______________ Brain OR small bowel cancerOvarian, stomach, kidney/urinary tract10 or more colon polyps found in a lifetime _______________________________________ _______________ ................
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