Preconception Visit Form

  • Woman Wise Integrative Gynecology Preconception Visit: New Patient Questionnaire

    General Information
  • Date Completed*
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  • Genetic Background*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Current Health Care Providers & Lab Work

  • Approximately when was the last time you had blood work & what lab used?:*

  • Insurance

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  • Format: (000) 000-0000.
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  • Pharmacy Details

  •  *   *   *   *            

  • Relationship Status*
  • Who do you live with? (check all that apply)*
  • Employment Status*

  • Pregnancy Planning

  • If you have been trying to conceive, have you tried any of the following?*

  • Your Health Story In Your Words

    Every woman has her own story that had made her who she is today. Some may think their life story is pretty unremarkable, while others really feel the impact of their past on their present health status. Please feel free to share anything you wish for me to know, so I can better understand you and your current health challenges.

  • YOUR MEDICAL HISTORY

    Please check the correct box indicating if this is a condition you have currently or have had in the past. Leave blank if it does not apply.

  • Energy Level

  • ENERGY/FATIGUE LEVEL*
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  • ENERGY/FATIGUE LEVEL*
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  • Allergies

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  • FAMILY HEALTH HISTORY

  • Has anyone in your family been diagnosed with: the following?*
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  • YOUR BIRTH/CHILDHOOD

  • DENTAL HISTORY

  • Check if you have any of the following:*

  • ENVIRONMENTAL EXPOSURES

  • Do any of these significantly affect you?*
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  • In your work or home are you exposed regularly to: (check all that apply)*
  • Check all that apply*

  • ELIMINATION HISTORY

    We take pooping seriously! If you aren't pooping regularly, your health is suffering.
  • Frequency of Bowel Movements*
  • Please select which Type of stool on the Bristol Stool Chart most accurately reflects your stools most of the time.*
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  • Do you frequently use:*

  • OBSTETRIC HISTORY

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  • MENSTRUAL HISTORY

  • Date of First day of Last Period
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  • How would you describe your periods? (Check all that apply)
  • Please Indicate the products you use during your period (may select more than one)*
  • What color is your period blood typically for the majority of the flow?*
  • Do you experience cramping with most cycles?*
  • Do you experience any of the following premenstrual problems that improve a few days into your period? (Select all that apply)*

  • GYNECOLOGIC HISTORY

    Your honesty with these questions will help me provide you with the best care. This is all confidential information and will not be shared without your consent.

  • GYNECOLOGIC SCREENING & PROCEDURES

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  • Please check all that apply regarding sexual activity*
  • Have you every been diagnosed with or told you had: (Please check all that apply)*
  • Have you ever been diagnosed with any of the following STI's? (Please check all that apply)*

  • NUTRITION & DIETARY HABITS

  • Check all the factors that apply to your current lifestyle and eating habits:*
  • Describe your food environment growing up:*
  • Who does the grocery shopping in your household?*
  • Please check which beverages you drink regularly (at least once every 2 days)*
  • How many caffeinated beverages do your drink per day?*
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  • PHYSICAL ACTIVITY

  • Which most closely describes you? (check all that apply)*
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  • STRESS

    We al have it, please share with me a bit about yours
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  • Stress Management

  • SLEEP

  • Please check all that apply*

  • MAKING LIFE CHANGES FOR YOUR HEALTH

  • Please indicate any forms of complementary care you have tried. or check "None"*

  • Readiness Assessment

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  • ALL PATIENT INFORMATION IS HANDLED UNDER THE HIPPA PRIVACY ACT - CONFIDENTIAL / HIPPA APPROVED FORM

  • Notice Of Privacy Practices

  • The privacy of your medical information, as described in the HIPPA Privacy Act, is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at our organization. We need this record to provide you with quality care and to comply with certain legal requirements. We will not use or disclose your medical information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to us at the address provided at the end of this notice. We may share medical information about you to doctors & other health care providers to assist them in treating you only with your written permission. We may include your medical information on a superbill provided to you to submit to your insurance company for payment purposes. 

    Woman Wise Integrative Gynecology, LLC

  • Informed Disclosure/Consent To Treat

  • I consent to outpatient gynecologic care and treatment by Katherine O’Brien MS, CNM at Woman Wise Integrative Gynecology, LLC.   I understand she has a masters degree as an Advanced Practice Nurse. Her area of focus is Miwifery, which at Woman Wise Integrative Gynecology, LLC will only include gynecologic services.  She will not provide prenatal, delivery, or postpartum care.  She is not a medical doctor and will let me know when something is beyond her level of expertise and I need to seek care elsewhere.  I understand that I am advised to maintain a relationship with a primary care provider, who is not Katherine O'Brien MS, CNM, for my general health care.  I understand that Katherine O'Brien MS, CNM does not provide emergency care or treat any type of breast or gynecologic cancer.

    I am aware that gynecology and lifestyle medicine approaches to common gynecologic problems are not an exact science and that no guarantees have been made regarding the results of treatment.  I agree to participate in an active manner, monitor my progress, and report any concerns to Katherine O'Brien MS, CNM. I also understand that any significant symptoms should be reported to my doctor. 

     

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