Escondido OB-GYN Medical Group, Inc. dba. 488 East Valley Parkway, Escondido, CA 92025

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1 We appreciate you choosing North County Women s Specialists for your healthcare needs. We continually strive to provide the highest quality gynecologic and obstetric healthcare in a professional caring environment. Enclosed is your new patient packet for completion. This packet needs to be completed and returned 2 days prior to your appointment. Failure to do so may result in your appointment being rescheduled. You must bring your insurance card or proof of insurance to all your all appointments. Co-payments and/or deductibles, if applicable, are required to be paid at the time of your visit. To be able to provide you with the best medical care possible, we recommend that if you have children under the age of 8, to please not bring them with you to your appointment. Lastly, we ask that you arrive on time to your appointment. Please be advised that if you are more than 15 minutes late to your appointment, we will need to reschedule. Thank you for your cooperation. We look forward to taking care of you. North County Women s Specialists Enclosures 1/15

2 RTH COUNTY WOMEN S SPECIALISTS Note: This information is confidential and will not be revealed to anyone without your permission Name Date Date of Birth / / Age Height: ft. in. Weight: Occupation: Ethnicity: Marital Status: Name of Spouse/Partner: *If you are interested in any cosmetic treatments (Botox, Juvéderm, or Latisse), please check Chief Complaint/ History of Present Illness: (Please be specific) In the case of an emergency, would you consent to a Blood Transfusion Past Medical History Have you ever had any of the following? Anemia Cancer Epileptic attacks Asthma Heart disease sease of gallbladder Migraines Pneumonia High blood pressure Blood transfusion Liver disease Diabetes Rheumatic fever Pelvic infection Depression / anxiety Anemia sickle cell Mitral Valve prolapse Bladder infections Problems with drugs or alcohol Blood clot in leg / lung Thyroid problem Genital herpes Chlamydia/syphilis/gonorrhea of minerals in bones (Osteopenia) Last colonoscopy Last bone density test Last cholesterol test Are you taking any medicines? (if answered Yes, list all-if need use separate sheet) Do you have allergies? (if answered Yes, list all) Past Surgical History Year Name of Surgery/Hospitalizations Past Obstetrical History Please list all pregnancies in order (including miscarriages, premature births, abortions, etc.): DOB (birth of baby) mo/day/yr GA WKS How many wks when delivered LENGTH of LABOR hours in labor BIRTH WT lbs. SEX M/F TYPE OF DELIVERY VAG/CSECT EPIDERAL Y/N COMPLICATIONS Social History Do you smoke? How many cigarettes? When did you start Do you drink alcohol? Do you use any drugs? smoking? How often do you drink? At what age did you start drinking? If yes, please specify: 2

3 RTH COUNTY WOMEN S SPECIALISTS Note: This information is confidential and will not be revealed to anyone without your permission Name Date Date of Birth / / Age Past Gynecological History Age of first period Cycle length: Pain or Cramping with periods? Are your periods regular? Flow: Heavy Are you sexually active? Method of birth control Date of the beginning of last menstrual period? Date of the last Pap Have you ever had an abnormal Pap? Have you had treatment due to an abnormal Pap? (Please indicate when?) Date of your last mammogram Was it normal? Family History (Has any of your relatives ever had) Who Who Who Hereditary disease Heart problems Mental illness Cancer High blood pressure Embolism Diabetes Problems with the kidneys TB Epilepsy Anemia sickle cell Bleeding problems Review of symptoms Do you currently have any of the following problems? Physical Cardiovascular Psychiatric Symptoms Fever/chills Chest pains Depression/crying Weight loss Difficulty breathing Anxiety Headaches Swelling Thinking about suicide Palpitations Eyes Respiratory Skin Blurred vision Wheezing Rash/sores Double vision Shortness of breath Mole changes Changes in your vision Cough Sleep apnea Allergies Musculoskeletal Breasts Hay fever Joint pain Nipple Discharge Medicines Muscle weakness Lumps Muscle pain Skin changes Neurological Ear/nose/throat/mouth Genitourinary Dizziness Sore throat Urine leakage Seizures Sinus problem Urine retention Numbness/tingling Hearing Problem Burning with Urination Hot flashes Frequent Urination Excessive thirst Vaginal discharge Endocrinologist Abnormal bleeding Hair loss Hematologic & Lymphatic Painful Periods Heat/cold intolerance Swollen glands Pain with intercourse Frequent bruising Fibroids Gastrointestinal Infertility Nausea/vomiting Constipation/diarrhea Abdominal pain 3

4 PERMISSION TO FURNISH MEDICAL INFORMATION Initial here if you wish us to furnish information ONLY to you. In this instance, we will leave a message for you to call our office if you are not immediately available. OR Please list persons to whom we may furnish medical information about you (example: blood test results, other test results, doctor s instructions, etc.) in the event you are not immediately available. Unless otherwise indicated, we will leave a message on your answer machine or voice mail with any routine results or instructions. THIS AUTHORIZATION WILL BE IN EFFECT UNTIL REVOKED IN WRITING Approved Person(s) Relationship to you Patient Name (please print) Signature Date of Birth Date 4/15

5 Acknowledgement of Receipt of Cord Blood Information Dear Patient, California state law requires care providers to inform expecting parents of their options regarding preserving umbilical cord blood stem cells. Did you know that umbilical cord blood stem cells can be used to treat nearly 80 diseases, including several forms of cancers and blood related diseases, immunity and metabolic disorders and disease, such as leukemia and lymphomas? Future applications such as a regenerative medicine are also an emerging area of medicine that will help treat many diseases that have previously been thought to be untreatable. Certainly, there are over 3,000 clinical trials worldwide, that involve researching the application of stem cells to treat injuries and diseases, and that number will continue to grow. Acknowledgement of Receipt of Cord Blood Information Patient Name Patient Signature DOB Date Should I wish to obtain additional information about umbilical cord blood stem cell preservation, I fully understand that this responsibility will be solely and completely my own. Please ask us if you would like to more information. 6/15

6 Drug Screening Consent PATIENT: DOB: Please Print In order to ensure the health of my baby, my urine and/or blood may be screened for drugs at the discretion of my physician. Patient Signature Date Witness (Medical Assistant or Provider) Doctor of Record 7/15

7 OBSTETRICAL GENETICS WORKSHEET NAME: DOB: 1. Were any of your children born with birth defects? YES 2. Is anyone on either side of the family mentally retarded? YES 3. Does anyone on either side of the family have birth defects? YES 4. Is there any disease that runs in the family? YES 5. Have you ever had chicken pox or been vaccinated against the illness? YES 6. If you have a baby boy would you like him to have a Circumcision? YES 7. If you or the baby s father is black, have you ever been tested for sickle YES trait or disease? 8. Are you interested in further information regarding saving your babies YES cord blood? 9. Have you had any type of illness with the pregnancy? YES 10. Are you interested in getting permanently sterilized after the birth of your baby? YES 11. Have you been exposed to any toxic chemicals? YES 12. Is there any possibility that you or your husband are related? YES 13. Have you ever had an abnormal pap smear? YES 14. Have you ever had surgery on your cervix? YES 15. Are you under the care for any problems by any other physicians? YES If yes please list 8/15

8 Genetic Disease Screening Information Carrier screening is available for some genetic diseases. Offering screening is based on how common a disease occurs in a group of people. These diseases are recessive; meaning that both parents must carry an abnormal gene for the disease to be present in their child. Important things to consider in deciding whether to be screened for genetic disease: 1. The decision to be tested for genetic disease carrier status is completely mine. 2. My partner and I may carry non-working genes, be healthy, have no affected relatives and still have a baby with disease. 3. Certain diseases are more common among certain ethnic groups. Disease uncommon in an ethnic group may be more difficult to test for. 4. Normal test results do not ensure the birth of a healthy baby. These tests look for a specific disease, not all possible genetic diseases. Rare forms of the disease tested for may not be detected. 5. If I am a carrier, testing the baby s biological father will help us learn more about the chance of your baby having a disease. I understand that genetic testing may identify mistaken paternity. 6. Determining my own risk for genetic disorders may affect the risk estimates for my family members. 7. If both parents are carriers, there is still a good chance that the baby will not have the disease. Parental testing can be done to determine if the baby will be affected. 8. I understand that it is not possible to accurately predict the severity of a disease in an affected child based on genetic testing. 9. I understand that if a baby has inherited non-working genes from both parents, medical care can help with symptoms but these diseases can not be cured. 10. I understand that my insurance carrier might not cover the cost of genetic screening. If my insurance carrier does not cover any part of my testing, I will be responsible for any balance due. 11. My decision to proceed with or decline genetic testing will not impact any other aspect of my medical care. 9/15

9 Below is a brief description and consent for carrier screening of some relatively common genetic diseases. If you are not certain about being tested for these genetic diseases, please ask your health care provider for more information before signing this form. A. CYSTIC FIBROSIS mainly affects Caucasians and Ashkenazi Jews. Cystic Fibrosis can cause lung, digestive and reproductive problems. Life expectancy with modern medical care is about 40 years. About 1 in 29 Caucasians and Ashkenazi Jews carries a non-working cystic fibrosis gene. Screening detects most, but not all carriers. A negative carrier screen in one or both parents does not completely eliminate the chance of having a baby with cystic fibrosis. I want cystic fibrosis carrier testing. (DNA analysis) I do not want cystic fibrosis carrier testing. B. SICKLE CELL ANEMIA mainly affects persons of African descent. Sickle cell causes painful blood clotting problems. Life expectancy with modern medical care is about 40 years. 1 in 10 African Americans carries a sickle cell anemia gene. Screening detects most sickle cell anemia carriers. THALASSEMIA mainly affects persons of African, Southeast Asians, Mediterranean, Middle Eastern & Indian Subcontinent (Pakistan/India) descent. Thalassemia may cause miscarriage and anemia. All carriers may not be detected. I want sickle cell anemia and thalassemia carrier testing. (Hemoglobin analysis) I do not want sickle cell anemia and thalassemia carrier testing. C. TAY-SACHS DISEASE and CANAVAN DISEASE mainly affects persons of Ashkenazi Jewish descent. Tay-Sachs and Canavan disease cause nervous system problems. Affected persons usually die in childhood. 1 in 30 Ashkenazi Jews carries a non-working Tay-Sachs gene and 1 in 40 carries a non-working Canavan gene. Screening detects most disease carriers. I want Tay-Sachs and Canavan disease carrier testing. (DNA analysis) I do not want Tay-Sachs and Canavan disease carrier testing. Patient Name: Date of Birth: Signature: Date: Witnessed By: (Medical Assistant or Provider) 10/15

10 Patient Information And Consent For Prenatal Genetic Screening And Testing Down syndrome is the most common cause of severe learning disabilities in children, occurring in about 1 of every 700 births. Down syndrome is also called trisomy 21. There is no way to prevent Down syndrome, but it is possible to perform tests that indicate if a pregnant woman's developing fetus has a increased risk of having Down syndrome. Testing can be done at the end of the first trimester and/or at the beginning of the second trimester. The most accurate test is one that uses information from tests done during both the first and second trimesters (called integrated testing). A child who is affected will have moderate to severe learning disabilities, low IQ, a characteristic physical appearance (flat face, slanting eyes), and often have heart defects. Other problems can also occur. Although life expectancy was once substantially shortened, it is now possible for people with Down syndrome to live about 50 years. What is a screening test? Screening tests measure chemicals in blood from the woman, and combine these results with the woman's age and sometimes with results of ultrasound testing of the fetus, to estimate risk. Screening tests do not diagnose Down syndrome; rather, the tests identify women who have an elevated risk of having a child with Down syndrome. FIRST TRIMESTER TESTING Blood tests Blood tests measure normal substances (called markers) in the mother's blood that are secreted by the placenta or the fetus. The blood test is done between 10 and 13 weeks of pregnancy and checked for levels of two or more pregnancy proteins. One protein that is always measured is called PAPP-A (pregnancy-associated plasma protein-a). Its levels tend to be lower than usual in pregnant women carrying a fetus with Down syndrome. The other proteins that can be measured are total hcg, and inhibin A. The levels of these proteins tend to be higher than usual in pregnant women carrying fetuses with Down syndrome. Ultrasound examination or NT Scan An ultrasound examination is performed between 10 and 13 weeks of pregnancy to measure the size of the naturally occurring fluid-filled space at the back of the baby's neck (called nuchal translucency). Thickening in this area can be a sign of Down syndrome, although thickening can also be found in normal fetuses. SECOND TRIMESTER TESTING Tests of the mother's blood drawn during the second trimester (between 15 and 20 weeks of pregnancy) may be used to estimate the risk of having a baby with Down syndrome, as well as 3 other genetic abnormalities. These blood tests measure normal substances (called markers) in the mother's blood that are secreted by the placenta or the fetus. The markers that are used in the screening process include alpha-fetoprotein (AFP), unconjugated estriol (ue3), human chorionic gonadotropin (hcg), and inhibin A. The blood levels of the markers are interpreted after considering the woman's age and other factors. All of the information is used together to calculate the woman's risk of carrying a baby with Down syndrome. However, abnormal patterns can exist in a small percentage of normal pregnancies. Therefore, if the test suggests an increased risk of Down syndrome, further testing is needed to determine if a fetal abnormality is present and to identify the abnormality. Risk calculation A woman's individual risk is calculated from her age, the age of the fetus, and the results of the screening test. If there is any uncertainty about the gestational age of the fetus, an ultrasound will be recommended.

11 Escondido OB/GYN dba North County Women s Specialists INTEGRATED TESTING The integrated test is done in two parts. The first part is done during the first trimester, and includes an ultrasound examination of the fetus to measure nuchal translucency and a test from the mother's blood to measure PAPP-A. The second part is done at 15 to 20 weeks of gestation, which tests the mother's blood level of alpha-fetoprotein, unconjugated estriol, hcg, and inhibin A. The results of the first and second parts of the test are integrated (combined) to give a single number that estimates the fetus' risk of Down syndrome. This estimate is reported after the second trimester testing is completed. The full integrated test detects 85 percent of fetuses with Down syndrome and only about 1 percent of women who are screened have a false positive result (when the screening test is positive but the infant does not have Down syndrome). The false positive rate of first or second trimester testing alone is at least 5 percent. Thus, with integrated testing, fewer women will need to undergo a procedure to examine the baby's chromosomes (amniocentesis). However, the integrated test has the disadvantage of not providing definitive results until later in pregnancy (typically after 16 weeks of gestation). AFTER A POSITIVE TEST A woman who has a positive screening test can choose to have further testing to determine if the baby is affected by Down syndrome. If a woman chooses not to have further testing during pregnancy, the infant may be tested after birth, if necessary. Genetic counseling can help parents balance the risks, limitations, and benefits of prenatal screening and diagnostic testing. Talking with a counselor can also help parents identify the issues involved in ending a pregnancy or raising a child with Down syndrome. Two tests are available to definitively diagnose Down syndrome: chorionic villus sampling and amniocentesis. Both CVS and amniocentesis are invasive tests that have a small risk of miscarriage. Therefore, these tests are typically performed only in women who are at increased risk for Down syndrome or another chromosome abnormality. CHORIONIC VILLUS SAMPLING Chorionic villus sampling (CVS) is a test that may be used to examine the baby's chromosomes during the first trimester of pregnancy. The test involves using a needle or catheter to remove a small tissue sample from the placenta. The needle is inserted through the abdomen or the cervix, and the cells are examined for chromosomal abnormalities. The test is performed between 10 and 13 weeks of gestation, and has a small risk of damaging the placenta, which leads to miscarriage in about one of every 100 women who have CVS. Genetic disorders that can be diagnosed from DNA analysis can be determined with CVS or amniocentesis. Neural tube defects in the fetus cannot be detected by CVS. AMNIOCENTESES For amniocentesis, a physician uses a thin needle to extract a small amount of amniotic fluid from the uterus while the procedure is monitored with ultrasound. Fetal cells in the amniotic fluid are examined for Down syndrome or other chromosomal problems. The procedure is done any time after 14 weeks of gestation. Amniocentesis is believed to have a small risk of miscarriage compared to CVS; for every 200 women who have an amniocentesis, approximately one woman will have a miscarriage. The most common reason amniocentesis is done is to perform genetic tests on a fetus who could be at increased risk of specific genetic abnormalities. A typical genetic amniocentesis result gives information about the number of chromosomes (as an example, there is an extra chromosome in Down syndrome and one missing in Turner syndrome), the sex of the baby, and whether there is an increased risk of some birth defects, such as open spina bifida. It does not show whether the baby has other inherited or genetic disease unless the lab is told to test for a specific disease because of a family or obstetrical history which places the baby at risk for the same problem. Also, some problems cannot be detected by this testing. Therefore, a normal test result does not guarantee that the baby will be normal. TIME FRAME Amniocentesis for genetic studies is usually performed between the 15th and 20th week of gestation. Earlier procedures, called early amniocentesis, are done before 15 weeks of pregnancy. Because they are done earlier in pregnancy, results are available at an earlier gestational age but the risk of pregnancy loss is higher. Procedures performed after 20 weeks can be problematic if termination of pregnancy is planned based upon abnormal results. 12/15

12 Escondido OB/GYN dba North County Women s Specialists Prenatal Genetic Screening Consent orm NT or Nuchal Translucency is a comprehensive ultrasound, performed before 14 weeks of pregnancy, which measures the thickness of the fetuses back of the neck which is a precursor for Down syndrome and other syndromes as well. The NT scan is done in conjunction with the 1 st trimester blood draw. First trimester screening is a non-invasive blood draw, from the mother, performed between 10 weeks and 13 weeks and 6 days of pregnancy. Second trimester screening is a non-invasive blood draw, from the mother, performed between 15 weeks and 20 weeks of pregnancy. CVS is an invasive test performed in between 10 weeks and 13 weeks of pregnancy. The test involves taking a small sample of tissue from the placenta to measure the chromosomes. Amniocentesis is an invasive test performed anytime after 15 weeks of pregnancy. The test involves an ultrasound guided needle into the amniotic sac to withdraw a small sample of amniotic fluid which gives us the number of chromosomes, the sex of the baby, and whether there is an increased risk of other birth defects. Please circle either I do or I do not I do / I do not desire the (NT) Nuchal Translucency screening. I do / I do not desire to undergo first trimester genetic screening. I do / I do not desire to undergo second trimester genetic screening. I do / I do not desire to undergo invasive genetic testing (CVS or Amniocentesis). Patient Name: Date of Birth: Signature: Date: Witness: (Medical Assistant or Provider) 13/15

13 AUTHORIZATION FOR RELEASE OF INFORMATION ASSIGNMENT OF BENEFITS PAYMENTS OF ACCOUNT I authorize Escondido OB/GYN dba North County Women s Specialists to release medical information for insurance purposes concerning my treatment while under their care. I authorize payment of any Insurance Benefits for medical or surgical services directly to Escondido OB/GYN dba North County Women s Specialists. I agree to pay any fees not covered by my Insurance Benefits directly to Escondido OB/GYN dba North County Women s Specialists within 30 days of receiving a bill. If my account is forwarded to a collection agency, I agree to pay all collection fees. Signature: Date: Print Name: Date of Birth: 14/15

14 Acknowledgement of the Notice of Privacy Practices I hereby acknowledge that a copy of the Notice of Privacy Practices for North County Women s Specialists is available to me upon request. A copy of this notice is posted in the reception area and may be viewed if so desired. Signature: Date: Print Name: DOB: Physician s Name: If not signed by patient, please indicate: Relationship Parent or guardian of minor patient Guardian or conservator of an incompetent patient Name of Patient: 15/15

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