Patient Resources Elite Women's Care Patient Demographics Patient's Legal Name Last * First * Middle Gender: * FemaleMaleNonbinary Mailing Address * Include City, State, and Zip Code Street Address Include City, State, and Zip Code Home Phone: Include Area Code Cell Phone: * Include Area Code Email * Date of Birth: * Social Security Number: Current Marital Status * SingleMarriedDivorcedWidowed Choose One Living Will: * YesNo Primary Care Provider: * Spouse's Name: Spouse's Date of Birth Spouse's SSN: If insured through spouse Emergency Notification: * Not Living In Same Household Emergency Notification Phone: * Include Area Code Responsible Party Relationship to Patient * SelfOther Relationship to Patient * Responsible Party Phone Number: * Include Area Code Responsible Party Date of Birth: * Social Security Number: Mailing Address Include City, State, and Zip Code Street Address Include City, State, and Zip Code Patient Information Race: * WhiteBlack or African AmericanAmerican Indian or Alaskan NativeAsianNative Hawaiian or other Pacific IslanderDeclined Ethnicity: * Hispanic or LatinoNot Hispanic or LatinoDeclined Language: * EnglishSpanishIndianJapaneseChineseKoreanFrenchGermanOther Employment Status: * Full-TimePart-TimeUnemployedSelf-EmployedRetiredActive Military Patient Employer * Patient Work Phone: Include Area Code Student Status: * Full-Time StudentPart-Time StudentNot a Student Pharmacy Name: * Pharmacy Address or Cross Street: * Pharmacy Phone Number: How Did You Hear About Our Office? * Health History Reason For Visit * Medications/Herbals or Vitamins: : ( name, dosage and directions-feel free to attach a separate list) * Allergies: Medication/Environmental/Food (If Yes, please specify medication and reaction) * Medical History: (please select Yes or No) Cancer * YesNo Type of Cancer Asthma/Lung Disease * YesNo Hypertension * YesNo Bleeding/Clotting Disorder * YesNo Diabetes * YesNo Autoimmune Disorder * YesNo Psychological Disorder * YesNo Stroke * YesNo High Cholesterol * YesNo Tuberculosis * YesNo Osteopenia/Osteoporosis * YesNo Neurological Disorder * YesNo Heart Disease/Attack * YesNo Thyroid Disorder * YesNo Hepatitis/Liver Disease * YesNo Other: If you answered yes to any of the above questions, please explain. Include date, treatment received and if available, physician treating the condition: Have you had a blood transfusion? * YesNo If yes: When? GYN History: (please select Yes or No) Date of Last Pap * UnknownNeverProvide Date Date of Last Pap Normal or Abnormal * NormalAbnormal History of Abnormal Pap Smears: * YesNo HPV vaccine: * YesNo Length of periods (days): * Number of days between periods: * Sexually active: * YesNo Your partner(s): * MaleFemaleBothOther Date of last mammogram: * UnknownNeverProvide Date Date of last mammogram: Mammogram Normal/Abnormal: * NormalAbnormal Date of bone density: Bone Density Normal/Abnormal: NormalAbnormal How do you prevent pregnancy: Age of first period: * Age at onset of menopause: Last menstrual period: History of STD's Pregnancy History: (please select Yes or No) # of pregnancies: * # of miscarriages: * # of abortions: * # of C-Sections: * # of Living Children: * Surgical History: Surgical History: (what type of surgery and when) * If none, please use the answer none Date of Last Colonoscopy: Hospitalizations: (which hospital, when and the reason for admission/ER visit) * If none, please use the answer none If over 65, have you fallen in the past year? If so, what caused the fall(s) (such as dizziness, related to medication, low blood sugar, tripped, etc.)? Family History: Breast Cancer NoYes Maternal / Paternal MaternalPaternalMaternal & Paternal Family Member MotherSisterGrandmotherAuntOther Family Member Ovarian Cancer NoYes Maternal / Paternal MaternalPaternalMaternal & Paternal Family Member MotherSisterGrandmotherAuntOther Family Member Uterine Cancer NoYes Maternal / Paternal MaternalPaternalMaternal & Paternal Family Member MotherSisterGrandmotherAuntOther Family Member Colon Cancer NoYes Maternal / Paternal MaternalPaternalMaternal & Paternal Family Member MotherSisterGrandmotherAuntFatherBrotherGrandfatherUncleOther Family Member Osteoporosis NoYes Maternal / Paternal MaternalPaternalMaternal & Paternal Family Member MotherSisterGrandmotherAuntOther Family Member Pancreatic Cancer NoYes Maternal / Paternal MaternalPaternalMaternal & Paternal Family Member MotherSisterGrandmotherAuntFatherBrotherGrandfatherUncleOther Family Member Other Maternal / Paternal MaternalPaternalMaternal & Paternal Family Member MotherSisterGrandmotherAuntFatherBrotherGrandfatherUncleOther Family Member Social History: Caffeine (drinks or caffeine containing drugs) * YesNo If Yes: How Much? * Tobacco * YesNo If Yes: How much per day? * How long used? * Alcohol * YesNo If Yes: How much per day? * How long used? * Drug Use (illicit or non-prescribed) * YesNo If Yes: How often? * What Type? * Domestic Abuse * YesNo If yes: Past or Present * Specialists: (name of physician and condition treated) Today's Date * Patient (or Responsible Party) Signature: * Clear HIPAA Consent I understand that as part of my healthcare, Elite Women’s Care, originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future treatment. I understand that this information serves as: A Basis for planning my care and treatment; A means for communication among health professionals who contribute to my care, such as referrals; A source of information for applying my diagnosis and treatment information to my bill; A means by which a third-party payer can verify that services billed were actually rendered; A tool for routine healthcare operations, such as assessing quality and reviewing the competence of staff. I understand that as part of treatment, payment or healthcare operations, it may become necessary to disclose health information to another entity, i.e. referrals to other healthcare providers. I consent to such disclosure for these uses as permitted by law. I fully understand and Select One * accept decline this consent. Notice of Privacy Practices I acknowledge that I have been informed of Elite Women’s Care Notice of Privacy Practices that provides a description of our practice’s uses and disclosures of Protected Health Information. I understand that I have the right to review the Notice of Privacy Practices and receive a copy before signing this statement. I understand that Elite Women’s Care has the right to change its Notice of Privacy Practices that will be effective for health information Elite Women’s Care already has about me, as well as any they receive in the future. Elite Women’s Care has posted a current copy of the Notice of Privacy Practices in our lobby for review. I understand that I may obtain a copy of the current Notice in effect upon request. I have read all of the above and understand/agree to all the provisions therein regarding responsibility for payment, permission for treatment and Notice of Privacy Practices. Requesting Medical Records From Our Office Our office requires patients and their representatives to sign an Authorization Form before release of medical records. Messages From Our Office and/or Appointment Reminders May we leave a message at your home using doctor’s/practice name? YesNo Phone #/Email to Use May we leave a message at your work using doctor’s/practice name? YesNo Phone #/Email to Use May we text you appointment reminders and other messages? YesNo Phone #/Email to Use May we email you appointment reminders and other messages? YesNo Phone #/Email to Use Please list all family members or other person(s), if any, whom we may disclose your protected health information, including treatment and payment information. These persons will have full access to your protected health information. Name Phone Number Name Phone Number Name Phone Number I have read, filled out and agree to all of the above. Patient/Guardian Signature: * Clear Patient Name if Different: Printed Name * Date * If other than the patient is signing, are you the legal guardian, custodian or have Power of Attorney for this patient for payment, treatment or healthcare operations? * Yes No Information Regarding Well Woman Visits If you have scheduled a well woman visit, the purpose of this visit is to focus on your wellness and preventative health maintenance. Therefore, we will be discussing ways to prevent common conditions. Your health insurance also limits what can be done during these visits. Well woman visits commonly include: Breast & pelvic exam Pap Smear STD testing HPV/gardasil vaccine discussion Birth control options discussion Order for a mammogram and/or bone scan (DEXA) Referral for a colonoscopy If there is something specific you would like to discuss, such as pelvic pain, heavy/irregular menstrual cycles, menopause symptoms, bacterial vaginosis, UTI symptoms, etc. we are happy to change your visit type and reschedule your well woman to a time when you are feeling well. Signature of Patient or Personal Representative * Clear Date General Consent for Care and Treatment TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s). This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services. You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions. I voluntarily request a physician, and/or mid-level provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination including but not limited to pelvic examination, testing and other treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s). I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents. Signature of Patient or Personal Representative * Clear Date * Printed Name of Patient or Personal Representative * Relationship to Patient Printed Name of Witness Employee Job Title Signature of Witness Clear Date Pelvic Examinations Consent Form Pelvic Examinations Consent Form Patient Name: * Date of Birth: * CONSENT: I, the above listed Patient or as the legally authorized person for the Patient, hereby consent to receiving pelvic examinations being performed by my physician or other health care practitioner, any medical student or any student receiving training as a health care practitioner. NATURE OF PELVIC EXAMINATIONS For the purposes of this Consent Form, a “pelvic examination” on a female means the series of tasks that comprise an examination of the vagina, cervix, uterus, fallopian tubes, ovaries, rectum, or external pelvic tissue or organs using any combination of modalities, which may include, but need not be limited to, the health care provider’s gloved hand or instrumentation. For purposes of the Consent Form, a “pelvic examination” on a male means examination of the rectum, prostate, and external tissue or organs, including the penis or scrotum using any combination of modalities, which may include, but need not be limited to, the health care provider’s gloved hand or instrumentation. I CONSENT TO RECEIVE PELVIC EXAMINATIONS AS DESCRIBED ABOVE, AND ALL MY QUESTIONS HAVE BEEN ANSWERED TO MY SATISFACTION. CONSENT: I, the above listed Patient or as the legally authorized person for the Patient, hereby consent to receiving pelvic examinations being performed by my physician or other health care practitioner, any medical student or any student receiving training as a health care practitioner. NATURE OF PELVIC EXAMINATIONS For the purposes of this Consent Form, a “pelvic examination” on a female means the series of tasks that comprise an examination of the vagina, cervix, uterus, fallopian tubes, ovaries, rectum, or external pelvic tissue or organs using any combination of modalities, which may include, but need not be limited to, the health care provider’s gloved hand or instrumentation. For purposes of the Consent Form, a “pelvic examination” on a male means examination of the rectum, prostate, and external tissue or organs, including the penis or scrotum using any combination of modalities, which may include, but need not be limited to, the health care provider’s gloved hand or instrumentation. I CONSENT TO RECEIVE PELVIC EXAMINATIONS AS DESCRIBED ABOVE, AND ALL MY QUESTIONS HAVE BEEN ANSWERED TO MY SATISFACTION. Patient’s Signature * Clear Patient’s Signature * Clear Date * Date * Legally Authorized Person Signature Clear Relationship to Patient Legally Authorized Person Printed Name Date Witness Signature Clear Witness Printed Name Date *Due to Senate Bill 698 that was recently signed by the Governor, a separate consent for pelvic examination is required for all patients being seen in the office IN ADDITION TO the consent to treat that is already required. Captcha Submit If you are human, leave this field blank.