lifecareforwomen.com - New Patient Form

MEDICAL HISTORY FORM
NAME

First NameLast Name
DOB

MonthDayYear
Date
DATE

MonthDayYear
Date
SSN
I. What brings you to see the Doctor?
II. Menstrual History
First date of last menstrual period

MonthDayYear
Date
Age when 1st period started
Age at menopause
Hysterectomy

YesNo
Are you cycles regular?

YesNo
Are you periods:

RegularIrregular
How many days do you bleed?
How long are your cycles (average in 28-30 days)
How many days of heavy flow?
Do you need double protection?

YesNo
Do you have bleeding between periods?

YesNo
Are you periods painful?

YesNo
How many days of pain per cycle?
III. Obstetrical History
Total number of pregnancies?
Miscarriages
Elective terminations
Living Children
IV. Gynecologic History
Date of last pap smear

MonthDayYear
Date
Have you ever had an abnormal pap?

YesNo
Have you ever had an infection of your uterus, tubes, or ovaries (PID)?

YesNo
Prior Gynecological surgeries
Have you ever had Chlamydia, gonorrhea, herpes, genital warts or any other sexually transmitted disease?

YesNo
Do you have frequent vaginal infections/abnormal discharge?

YesNo
Are you sexually active?

YesNo
Do you have more than one sexual partner?

YesNo
Do you have pain or bleeding with intercourse?

YesNo
When was your last Mammogram?
Was it normal?

YesNo
Any other significant past gynecological history?
V. Contraception
Current Method:

NoneCondomsTubal LigationPillsIUDNuvaRingESSURERhythmVasectomyDiaphragmWithdrawalFoamOther
VI. Family History

RELATIONSHIP

	AGE OR AGE AT DEATH	ILLNESS OR CAUSE OF DEATH
MOTHER
FATHER
SISTER
BROTHER

Any family history of:

DiabetesHeart DiseaseHigh CholesterolAlzheimer'sStrokesBreast CancerUterine CancerOvarian CancerOther CancersOsteoporosis
VII. General Medical History
Do you have any ongoing medical problems?
Prior surgeries?
List current medications:
List vitamins and herbal supplements including doses:
Allergies to medications and reaction:
Allergies to food and reaction:
Allergies to the environment and reaction:
List childhood illnesses:
Has your weight changed in the last year?

YesNo
If yes, how much

Do you have problems with the following?

	YES	NO
Head, eyes, ears, nose & throat (convulsions, visual difficulty, seizures, etc)
Breathing (cough, asthma, TB, valley fever)
Hypertension
Diabetes
Heart Disease (heart attack, palpitations, chest pain, murmur).
Breast Discharge (milky, watery, bloody), Pain, or Breast Lumps
Nausea, Vomiting, Diarrhea, Blood in Stool, Hepatitis
Kidney or Bladder Infection, Stones, Blood in Urine
Skin Problems (including excessive hair, hair loss, acne)
Emotional Problem (depression, suicide attempts, anxiety)

Please explain any Yes answer
VIII. Social History
Do you smoke?

YesNo
If so, how long have you smoked?
Years
Cigarretes per day
Did you smoke previously?
Years
When did you quit?
Do you drink alcohol?

YesNo
What and how much?
Do you use street drugs?

YesNo
Identify drugs
Do you exercise?

YesNo
What type and how often?
Do you eat a balanced diet?

YesNo
Occupation

Cancer Family History Questionnaire
Patient Name
Patient DOB

MonthDayYear
Date
Age
Gender
Healthcare provider
Today's Date

MonthDayYear
Date
Personal and Family History of Cancer
Adopted/ unknown family history

CANCER

	Yes/No	YOU - Age of Diagnosis	Parents/ Siblings/ Children	Age of Diagnosis	Relatives on your mother side	Age of Diagnosis	Relatives on your father side	Age of Diagnosis
BREAST CANCER
OVARIAN CANCER
UTERINE/ENDOMETRIAL CANCER
PROSTATE CANCER
COLON/RECTAL CANCER
PANCREATIC CANCER

OTHER CANCER(S)

FINANCIAL POLICIES

NO SHOW POLICY AND PATIENT RESPONSIBILITIES
SIGN AND DATE THIS PAGE TO CONFIRM YOU UNDERSTAND AND ACCEPT OUR POLICIES

The office of Dr. Linda Sodoma will bill your insurance as a courtesy. It is the responsibility of the patient to understand their insurance benefits, copays, deductibles and exclusions. Please make sure you understand your benefits completely.
- We expect your insurance to respond and pay claims-in 90 days or less. Our contract with insurance companies requires that we file your insurance claim in a timely manner, and we expect claim consideration and reimbursement to follow similar criteria. We will advise you if your carrier fails to pay your claim in a timely manner.
- Reimbursement policies for gynecology services vary substantially. This depends upon the policy you and/ or your employer have chosen. A call will be placed by this office in an effort to determine your benefits before treatment is rendered.
NOTE: A quotation of benefits by your carrier is not a guarantee of payment. Insurance Tiers will often quote a benefit and even authorize a procedure, but then not pay the claim for one of a number of reasons, including, but not limited to: pre-existing condition clauses, assignment of deductible, policy maximum, and coordination of benefits.
- You are required to notify this office of changes in your insurance status immediately. If your employment changes, so does your insurance. Insurance carriers have filing deadlines that must be met based on the date of service. Your failure to provide accurate, current information decreases the likelihood that your carrier will pay the claim and you will be responsible for those charges.
- There will be a $25 assessment for all returned checks: You will have to pay this charge before future appointments can be scheduled.
- Secondary claims are not filed automatically. We will file secondary claims upon your request for coinsurance and deductibles only. We will not file secondary carriers for copays.
- If you have an interruption of coverage during the course of obstetric care for any reason, this will mean that your care will have to be billed fee for service (itemized).This may result in higher coinsurance and deductible costs for You.
- All copays, deductibles and coinsurance are due at the time of service. This office accepts cash, checks, debit cards, MasterCard, Visa, AMEX and Discover credit cards. If you do not have your copay, your appointment may be rescheduled.
- Patient understands that there will be a $20.00 fee assessed for the completion of any insurance documentation, short term or long term disability forms, FMLA forms, leave of absence forms, or any other form of this nature.
- Patient will be advised that it will take 7- 10 business days to complete these forms, and should prepare for this interval when making requests.
- Medical record requests can take up to 10 days to process, and records will not be available to a patient the same day that the patient makes the request. The physician must review the chart before records can be copied and sent out.
- Patient/ guardian grants authority to Linda l. Sodoma DO PLC to deposit check payments issued by the insurer in two party format.
- Patient understands that Dr. Sodoma operates in good faith that the patient and the insurance company will reimburse the doctor for her time and care. In the event your insurance is terminated or fails to pay for office visits, procedures, injections, and/or hospitalizations, responsibility to pay the accrued debt resides with the patient.
- Failure to pay coinsurance, copayments, deductible assignments, and/ or non-covered services will result in the assignment of the delinquent debt to a collection agency.
- The patient will be responsible for any and all charges associated with the collection of the debt.
- Patient will check in no less than 10 minutes before the scheduled appointment time. If you are unable to keep your appointment, or will be late, please call the office to reschedule 24 hours prior to your scheduled appointment.
- A No-Show charge will be assessed if a call is not received 24 hours in advance of cancellations. Emergencies will be considered individually.
I understand and have had my questions answered regarding these policies and responsibilities. I acknowledge and agree that lam responsible for any and all portion of my bill not paid by insurance.
Patient/ Guardian Signature

Clear
Date

MonthDayYear
Date

Client/ Patient Confidentiality
I give my consent for my physician to view and maintain a copy of my Sure Scripts prescription history as part of my clinical medical record. I understand that this information will remain confidential and will not be transferred to outside entities without my written consent.

I also have received and understand the policies outlined in the HIPAA summary "Notice of Privacy Practices".
Coordination of Benefits
I am insured with (Insurance Company Name)
I do not carry a secondary insurance. I do carry a secondary insurance with (Insurance Company Name)
Patient Signature or legally authorized individual

Clear
Date

MonthDayYear
Date
Printed Name if signed on behalf of the patient
Relationship to Patient

HIPAA FORM

Request for Disclosure or Restriction of Health Information Linda I. Sodoma DO, PLC
Patient Name:
Date of Birth:

MonthDayYear
Date
Previous Name:
DISCLOSURE
I give permission for Name and Relationship to inquire about and receive information pertaining to my Protected Health Information (PHI) on my behalf.

**This consent shall remain in effect until Date or until revoked**
OR

RESTRICTION
I request that this office restrict the disclosure or use of my Protected Health Information (PHI) to certain individuals or for certain purposes as described below:
Patient Signature or legally authorized individual

Clear
Date

MonthDayYear
Date
Printed Name if signed on behalf of the patient
Relationship to Patient

	NEVER	MILD	MODERATE	SEVERE
1. Decline in general well being
2. Joint pain/muscle ache
3. Excessive sweating/hot flash
4. Sleep problems
5. Increase need for sleep
6. Irritability
7. Nervousness
8. Anxiety
9. Depressed mood
10. Exhaustion/lacking vitality
11. Declining mental ability/focus/concentration
12. Decreased muscle strength
13. Weight giant/belly fat/inability to lose weight
14. Breast tenderness
15. Rapid hair loss
16. Migraine headaches
17. Decreased desire/libido
18. Decreased ability to perform sexually/climax
19. Dry skin
20. Cold all of the time
21. Constipation
22. White spots on nails
23. Bruise easily
24. Loud noises bother
25. Frequent heartburn

	NEVER	SOME DAYS	MOST DAYS	EVERY DAY
1. Lack of Energy or Feeling Fatigued
2. Overall Decline in General Well Being
3. Joint & Muscle Aches or Pain
4. Hot Flashes or Night Sweats
5. Poor Sleep or Problems Staying Asleep
6. Irritable, Moody or Depression
7. Decreased Mental Focus or Memory
8. Decreased Muscle Strength
9. Weight Gain Regardless of Diet and Exercise
10. Sudden Hair Loss
11. Decreased Sexual Performance or Low Libido

MEDICAL HISTORY FORM

II. Menstrual History

III. Obstetrical History

IV. Gynecologic History

V. Contraception

VI. Family History

VII. General Medical History

VIII. Social History

Cancer Family History Questionnaire

Personal and Family History of Cancer

WELLNESS SCREEN

PATIENT WELLNESS SCREEN

PERSONAL INFORMATION

MISC. INFORMATION

INSURANCE INFORMATION

PRIMARY INSURANCE

SECONDARY INSURANCE

FINANCIAL POLICIES

Client/ Patient Confidentiality

Coordination of Benefits

HIPAA FORM

DISCLOSURE