New Patient, GYN Packet

Welcome!
Welcome to Alliance Obstetrics & Gynecology.

The following is a list of items you will need to have completed and/or bring with you to your appointment.
- Valid Picture ID (Driver’s License/State ID) - bring with you to your appointment
- Insurance Card(s) - bring with you to your appointment
Prior to your office visit, please check with your insurance company for your coverage and to see if an authorization is required for your appointment.

Thank you for choosing Alliance Obstetrics and Gynecology for your health care needs, we look forward to meeting you.
Patient Information
Demographics
Legal Last name:*
Legal First Name:*
Middle:
(Former name):
What is your preferred name?*
What are your preferred pronouns?
Is there any additional information you would like to share around your gender identity?
Marital Status*

SingleMarriedDivorced
Date of Birth:*

MonthDay Year
Date
Address*

Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Cell Phone:*
Home Phone:
Social Security Number:
Employer:
Employer Phone:
Race*

AsianNative HawaiianOther Pacific IslanderBlack/African AmericanWhiteUnreported/Refuse to ReportMore than one race
Ethnicity*

Hispanic or LatinoNot Hispanic or LatinoRefused to report
Language:*
Email Address:
Preferred Notification Method:*

PhonePostal MailPortal
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.

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PRIMARY INSURANCE:*
Subscriber's Name:*
Subscriber Date of Birth:*

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

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

MonthDay 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:
Signature*

Clear
Medical History
Please indicate if you need assistance with your visit? (i.e. wheelchair, interpreter service, etc):
Allergies
List the medications to which you are allergic, followed by your reaction to those medications:
Medications
Please fill out the following table with any medications, vitamins or over the counter supplements you are currently taking:

Medication Dose (amount) Frequency (how often taken)
1
2
3
4
5
6
7
8
9
10
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
COVID-19
GYN History
Last menstrual period:*
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?
*Type of Abnormal Pap:
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)
Are you currently sexually active?*

YesNo
Please indicate, are you sexually active with:*

MaleFemaleBothDecline
Are you currently using birth control?*

YesNo
Birth Control: Type (i.e. IUD, pills, condom, etc)
History of Pregnancy
If you have never been pregnant, please enter 0 in those fields.
Please list your total number of:*

Number
Pregnancies
Deliveries Vaginally
Deliveries C-Section
Induced Abortion
Spontaneous Abortion (Miscarriage)
Ectopic
Fetal Demise
Family History

	Date
Tetanus Shot
MMR Shot (measles)
Flu Shot
Pneumonia Shot
Shingles Shot
Varicella (chicken pox) Shot
Gardasil (cervical cancer) Shot
COVID-19

	Year
Cryotherapy
Laser
Cone Biopsy
Loop excision (LEEP)

	Number
Pregnancies
Deliveries Vaginally
Deliveries C-Section
Induced Abortion
Spontaneous Abortion (Miscarriage)
Ectopic
Fetal Demise

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 History
Occupation:*
Is a blood transfusion acceptable for you in an emergency*

YesNo
What is your exercise level?
How many times per week do you exercise?
Do you or have you ever smoked tobacco?
What is your level of alcohol consumption?
Are you currently using illicit drugs?*

YesNo
Illicit Drugs: Type
Illicit Drugs: Amount
Do you have a history of abuse?*

YesNo
History of abuse: Check all that apply.*

PhysicalMentalVerbalNone
Are you currently being abused?*

YesNo
Surgical History
Please list ALL procedures that you have had, along with the year performed:
Patient's Past Medical History
Have you previously been diagnosed with Cancer? If yes, please list the type and year diagnosed:
Have you had genetic testing for Cancer genes (BRCA, Lynch Syndrome...)? If yes, please list the type of testing and the results:
Do you have a history of Cardiovascular problems? If yes, please list the type and year diagnosed:
Do you have a history of Dermatological problems? If yes, please list the type and year diagnosed:
Do you have a history of Ear/Nose/Throat problems? If yes, please list the type and year diagnosed:
Do you have a history of Endocrine problems? If yes, please list the type and year diagnosed:
Do you have a history of Gastrointestional problems? If yes, please list the type and year diagnosed:
Have you had a history of any of the below Gynecological problems?

DysplasiaEndometriosisFibroidsInfertilityPCOS
Do you have a history of blood disorders? If yes, please list the type and year diagnosed:
Do you have a history of Respiratory problems? If yes, please list the type and year diagnosed:
Do you have a history of Musculoskeletal problems? If yes, please list the type and year diagnosed:
Do you have a history of Neurological problems? If yes, please list the type and year diagnosed:
Do you have a history of Psychiatric/Mood disorder? If yes, please list the type and year diagnosed:
Signature*

Clear
Should be Empty:

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

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

Patient Information

Medical History