New Patient, GYN Packet

Welcome!
Welcome to Alliance Obstetrics & Gynecology, PLLC.

In this packet you will find all the forms that must be completed prior to arriving. There will also be forms you will need to complete when you arrive for your first appointment.

The following is a list of items you will need to have completed and/or bring with you to your appointment.
- Patient Information - fill out online
- Alliance OB/GYN Medical History - fill out online
- Valid Picture ID (Driver’s License/State ID) - bring with you to your appointment
- Insurance Card(s) - bring with you to your appointment
PLEASE BE AWARE THAT RESCHEDULING WILL BE NECESSARY IF THE FORMS ARE INCOMPLETE AND/OR FAILURE TO ARRIVE 30 MINUTES PRIOR TO THE APPOINTMENT TIME.

If you are being referred to us by a physician or have an ongoing problem, please have the pertinent portion of your medical record forwarded to our office. If you are a self referral and have no ongoing problems, we do not need a copy of your medical records forwarded.

Prior to your office visit, please check with your insurance company to see if an authorization is required for your appointment. Also, please bring your insurance card so that we may copy it for our records.

This appointment time has been set aside for you and the provider to discuss your care. If you are unable to keep this appointment please notify our office 24 hours prior to your appointment. If you do not cancel your appointment in the designated time we may be unable to reschedule your appointment.

Thank you for choosing Alliance Obstetrics and Gynecology, PLLC for your health care.
Alliance Patient Financial Policy
I hereby authorize the release of any medical information necessary to process my insurance claim. I authorize payment to be made directly to Alliance Obstetrics and Gynecology, TIN #38-3381725. I have been provided with a copy of the Alliance Financial Policy and understand that I am financially responsible for any balance not covered by my insurance.

Please review the Alliance Patient Financial Policy.
Patient Information
Patient's last name: *
First Name: *
Middle:
Preferred to be called:
Is this your legal name? *

Yes No
If not, what is your legal name?
(Former name):
Marital Status *

Single Married Divorced
Date of Birth: *

Month Day Year
Date
Age: *
Sex: *

Male Female
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell Phone:
Home Phone:
Social Security Number:
Employer:
Employer Phone:
Race *

Asian Native Hawaiian Other Pacific Islander Black/African American White Unreported/Refuse to Report More than one race
Ethnicity *

Hispanic or Latino Not Hispanic or Latino Refused to report
Language:
Preferred Notification Method: *

Phone Postal Mail Portal
Email Address:
Family Physician First Name: *
Family Physician Last Name: *
Family Physician Phone:
Referring Physician First Name:
Referring Physician Last Name:
Referring Physician Practice:
Referring Physician Phone:
Insurance Information
Upload pictures of the front and back of your insurance card.

Browse Files
You can select multiple files Cancel of
PRIMARY INSURANCE: *
Subscriber's Name: *
Subscriber Date of Birth: *

Month Day Year
Date
Patient relationship to subscriber: *
If patient is a minor, Name of Guarantor
If patient is a minor, Guarantor's Date of Birth

Month Day Year
Date
Enrollee, Subscriber or Policy ID # *
Subscriber's Employer: *
SECONDARY INSURANCE:
Secondary Insurance Subscriber's Name:
Secondary Insurance Subscriber Date of Birth:

Month Day Year
Date
Secondary Insurance Patient relationship to subscriber:
Secondary Insurance Enrollee, Subscriber or Policy ID#
Secondary Insurance Subscriber's Employer:
Emergency Contact
Name of local friend or relative: *
Relationship to patient: *
Cell Phone:
Home Phone:
Work Phone:
Name *

First Name Last Name
Signature *

Clear
Covid-19 Vaccine Information
Have you received the Covid-19 vaccine?

Yes No
Please enter the date of your first Covid-19 vaccine.

Month Day Year
Date
Please enter the date of your second vaccine (if applicable).

Month Day Year
Date
Which vaccine did you receive? *

Pfizer Moderna Johnson & Johnson I have not received the vaccine.
Medical History

Check All That Apply to You
Breast

Breast Lump (benign) Breast Cancer Fibrocystic Disease of the breast Cyst of the Breast Nipple discharge Mastitis Breast Infection
Cancer

Brain Cancer Cervical Cancer Colon Cancer Lung Cancer Ovarian Cancer Rectal Cancer Skin Cancer* Stomach Cancer Thyroid Cancer Uterine Cancer Other Cancer**
*Type of Skin Cancer:
**Type of Other Cancer:
Cardiovascular

Blood Clot Heart Disease Hypertension Hypercholesterolemia Peripheral Vascular Disease Pulmonary Embolism Raynaud's Syndrome Rheumatic Heart Disease Heart Problem*
*Type of Heart Problem:
If you selected any of the above listed conditions, what doctor/office do you see?
Dermatological

Acne Ulcer of the skin Lupus
Endocrine

Goiter Graves' Disease Hashimoto Thyroiditis Hypothyroidism Partial Thyroidectomy Full Thyroidectomy Gestational Diabetes Insulin Dependent Diabetes Non-Insulin Dependent Diabetes Polycystic Ovarian Disease
If you selected any of the above listed conditions, what doctor/office do you see?
Gastrointestinal

Cholelithiasis Crohn's Disease Diverticulitis of the colon Cirrhosis of Liver Gastric Ulcer Irritable Bowel Syndrome (IBS) Ulcerative Colitis Acure Hepatitis Viral Hepatitis A Viral Hepatitis B Viral Hepatitis C Hemorrhoids
Genitourinary

Endometriosis Infertility Ovarian Cyst Kidney Disease Chronic Cystitis Kidney Stones Gonorrhea Chlamydia Lichen Sclerosis Premenstrual Dysthymic Disease History of Abnormal Pap* Interstitial Cystitis Pelvic Inflammatory Disease (PID) Genital Warts Herpes-Genital
*Type of Abnormal Pap:
Menstrual History

Bleeding or spotting between periods
Last menstrual period: *
How heavy is your flow during periods? *

Light Moderate Heavy

Please answer the following questions: *

	Yes	No
Do you have clotting during your periods?
Do you have painful cramping during your periods?

HEENT

Deafness Blindness Glaucoma Migraine with aura Migraine w/o aura
Hematological

Anemia Sickle Cell Anemia DVT/Pulmonary Embolism Hemophilia Von Willebrand's Disease Thrombophilia or clotting disorder
If you selected any of the above listed conditions, what doctor/office do you see?
Musculoskeletal

Arthritis Fibromyalgia Osteopenia Osteoporosis
Neurological

Migraine Migraine with aura Multiple Sclerosis Parkinson's Disease Myasthenia Graves Stroke Seizure Disorder
If you selected any of the above listed conditions, what doctor/office do you see?
Psychiatric

Alcohol Abuse Anorexia Nervosa Anxiety Disorder Depression OCD Schizophrenia Suicide Attempt Post-Partum Depression Bulimia Nervosa Borderline Personality Disorder
If you selected any of the above listed conditions, what doctor/office do you see?
Respiratory

Asthma COPD Sleep Apnea
Surgical History
Have you ever had any surgeries? *

Yes No

List the year for ALL procedures that apply to you. List ALL OTHER surgeries at bottom.

	Year(s)
D&C
Ovarian Surgery*
Hysteroscopy Removal of Polyp
Hysteroscopy Removal of Fibroid
Laparoscopy
Myomectomy
Infertility Surgery
Vulvar Surgery**
Hysterectomy - Vaginal†
Hysterectomy - Abdominal‡
Cesarean Section
Tubal Ligation (tubes tied)
Vaginal or Bladder Repaid for Prolapse or Incontinence
Endometrial Ablation

Other Surgery, type & date
Other surgery, type & date
Other surgery, type & date
*Type of Ovarian Surgery:
**Type of Vulvar Surgery:
†If yes, do you:

Still have cervix Still have both ovaries Still have one ovary
‡If yes, do you:

Still have cervix Still have both ovaries Still have one ovary
Allergies and Medications
Do you have allergies to medications? *

NO, I do not have allergies to medications YES, I have allergies to medications as listed below
List the medications to which you are allergic, followed by your reaction to those medications:

Other Allergies: *

	Yes	No
Iodine Allergy
Latex Allergy

Current Daily Medications, Vitamins, Over the Counter Supplements and Medical Devices

Please fill out the following table:

	Medication	Dose (amount)	Frequency (how often taken)
1
2
3
4
5
6
7
8
9
10

Family History

Indicate which, if any, family members have had the following conditions:

	Mother	Father	Brother	Sister	Son	Daughter	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Diabetes - Insulin Dependent
Diabetes - Non-Insulin Dependent
Heart Disease
Breast Cancer
Ovarian Cancer
Uterine Cancer
Colon Cancer
Blood clots (leg/lungs)
Thrombophilia
Stroke
Hypertension

Social / Sexual History
Do you have a history of abuse? *

Yes No
Are you currently being abused? *

Yes No
History of abuse: Check all that apply. *

Physical Mental Verbal None
Are you currently using tobacco (chewing or smoking)? *

Yes No
Tobacco: Amount
Tobacco: How frequently?
Are you exposed to second hand smoke? *

Yes No
Second Hand Smoke Exposure: Type
Second Hand Smoke Exposure: How frequently?
Are you currently using alcohol? *

Yes No
Alcohol: How frequently?
Alcohol: Amount
Are you currently using illicit drugs? *

Yes No
Illicit Drugs: Type
Illicit Drugs: Amount
Are you currently using birth control? *

Yes No
Birth Control: Type (i.e. IUD, pills, condom, etc)
Are you currently exercising? *

Yes No
Exercise: How often?
Exercise: Type
Martial Status: *
Living Situation: *
Occupation: *

Additional questions: *

	Yes	No
Are there religious beliefs affecting medical care?
Are you agreeable to receiving blood/blood products?

Please answer the following questions: *

	Yes	No
Do you wear a helmet?
Do you wear a seat belt?

Have you ever been sexually active? *

Yes No
Are you currently sexually active? *

Yes No
Number of sexual partners currently: *
Please indicate, are you sexually active with: *

Male Female Both Decline
Please specify any other relevant information:
History of Pregnancy
If you have never been pregnant, please enter 0 in those fields.

Please list your total number of: *

	Number
Pregnancies
Deliveries
Pre-Term Deliveries
C-Sections
Miscarriages
Abortions
Live Births
Ectopic Pregnancy

Have you had any of the following during pregnancy:

Gestational Diabetes Preeclampsia Multiple Gestation Twins Multiple Gestation Triplets Fetal Demise Placental Abruption Hemorrhage Pre-Term Labor
Immunizations

Indicate the date of your last immunizations. If you are unaware of the date or have not had, please indicate with N/A. *

	Date
Tetanus Shot
MMR Shot (measles)
Flu Shot
Pneumonia Shot
Shingles Shot
Varicella (chicken pox) Shot
Gardasil (cervical cancer) Shot

Health Maintenance

Please fill out the following table: *

	Date	Result	N/A
Last Mammogram
Last Colonoscopy
Last Bone Density
Last Pap
Last HPV

If you've ever had an abnormal pap, in what year?
If you've ever had treatment for an abnormal pap smear, what type of treatment have you had?

Have you ever had treatment for any of the following?

	Year
Cryotherapy
Laser
Cone Biopsy
Loop excision (LEEP)

Have you had a BRCA screening (blood test for breast cancer gene)? *

Yes No
Do you need assistance with your visit? (i.e. wheelchair, interpreter service, etc):
Copies of signed authorizations are available upon request. Form Revised 7/6/17
Should be Empty:

Covid-19 Vaccine Information