Client Registration. Work Status: Full Part time Retired Student Spouse/Partner's Name: Occupation:
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- Marilyn Dickerson
- 7 years ago
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1 Client Registration Social Security Number: Name: First ;Middle. Last: Address: City: Zip: ---- Mailing Address: ----:----: Home Phone: CelVother phone: Birth date: Marital Status: Employer: Occupation. Work Status: Full Part time Retired Student Spouse/Partner's Name: Occupation: Emergency Contact: Phone: Responsible Party (Primary Insurance Holder. If same as above leave blank) First Name: M.l. Last Name: _ Adilless: Home Phone: Birth date: Marital Status: S M D W Social Security Nwnber: Employer: Occupation: Work Status: Full Part time Retired Student Payment and Insurance Information Primary Insurance: Address: Phone Number: ID#: Group Name: Group#: Policy Holder: Birth date: Relation: Other Insurance: Address: Phone number: ID#: Group Name: Group#: Policy Holder: Birth date: Relation: Assignment of Benefits, Release of Information & Payment Agreement I understand that inside Passage Midwifery and Natural Medicine will be filing my insurance on my behalf. I agree to have the benefits from my insurance assigned to Inside Passage. I permit Inside Passage to release any information deemed necessary to any insurance or third party, within the guidelines ofhipaa (Health Insurance Portability & Accountability Act) I agree that I am responsible for full payment on this account. I agree if 60 days pass without payment or discussion of a payment plan, my account wi U be sent to collections and I will be responsible for the outstanding balance and any fees incurred in the collections process. Client signature: _
2 How to Reach Your Midwife Cell Phone: (907) If you have concerns about your pregnancy or baby, please feel free to call or text me on my cell phone any time of day or night. 2. If you are in labor or think you may be in labor, please call my cell phone. I don't typically wake up to texts. 3. During regular business hours, 9am-5pm Monday- Friday, please feel free to call or text 4. If you have a non-urgent question or concern outside of regular business hours, please me or wait until regular business hours. I value my family time and try hard not to interrupt it with texts that can wait. 5. If you do text me and I don't respond, please call me if you need immediate attention. If you have texted me and I don't respond during regular business hours, please call or text to remind me.
3 HIP AA Compliance Patient Consent Form Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient's rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent. The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive. By signing this form, l understand that: Protected health information may be disclosed or used for treatment, payment, or healthcare operations. The practice reserves the right to change the privacy policy as allowed by law. The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions. The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease. The practice may condition receipt of treatment upon execution of this consent. May we phone, , or send a text to you to confirm appointments? YES NO May we leave a message on your answering machine at borne or on your cell phone? YES NO May we discuss your medical condition with any member of your family? YES NO If YES, please name the members allowed: This consent was signed by: -----=-:-::--:-:c:--:-c:--:--=--::-:=-=----== (PRINT AME PLEASE)
4 I PC!s.s.C!ge MLolwLferlj Name: What was the flrst day of your last menstrual period? Was your period normal in length and flow? Aue your cycles regular? How many days in your cycle? How many days do your normally bleed? Date of positive pregnancy test: What day do you think you conceived? Is this a planned pregnancy? Most recent birth control used: Past Contraception: type, when, any problems: Previous Pregnancies: Total number of past pregnancies Full term deliveries: Premature deliveries: Miscarriages: Therapeutic Abortions: Cesarean section: Twins: Number of living children: Name of child Date of birth Boy or Girl? Weight at birth Home/hospital/birth center Length of labor Anesthesia/medications Episiotomy or tears? Breastfed? How long? Any Complications? High blood pressure, preeclampsia, shoulder dystocia, hemorrhage, retained placenta, Problems with baby or breastfeeding, etc.
5 Name: Medical History Please mark if you have any of the following conditions. In the space below record date, treatment and any follow-up care received. Also feel free to list any other conditions or concerns: Endocrine: diabetes, disorders involving thyroid, adrenal, pituitary or parathyroid glands, etc. Cardiovascular: high blood pressure, heart or valve problems, chest pain, etc. Gastrointestinal: abdominal pain, constipation, colitis, GERD/reflux, ulcers, etc Genitourinary: bladder infections, kidney infections, kidney stones, etc, Hematological: anemia, bleeding disorders, blood transfusions, thrombophlebitis, Rh disease. etc. Musculoskeletal: fractures, neck problems, back problems, scoliosis, injuries, arthritis, fibromyalgia Pulmonary: asthma, cough, pneumonia, pulmonary embolism, tuberculosis, etc. Neurological: epilepsy, seizure, strokes, neuropathy, headaches, head injury, etc. Autoimmune: lupus, multiple sclerosis, rheumatoid arthritis, celiac disease, etc Dermatological: eczema, allergy, psoriasis, warts, skin tags, etc. Mental/Emotional: depression, anxiety, eating disorders, addictions, postpartum depression, etc. Other: accidents, surgery, significant illness, domestic violence, etc. Gynecologic History: How old were you when you had your first menstrual period? VVhenwas yourlastpap? HaveyoueverhadanabnormalPap? If yes please explain Please check if you've ever had any of the following conditions or procedures: Yeast infection Pelvic Inflammatory disease Uterine fibroids Bacterial vaginosis Cervicitis Uterine surgery Chlamydia Cervical polyps Breast lumps Gonorrhea Ovarian cysts Breast surgery Syphilis Polycystic ovarian syndrome, PCOS Repeated miscarriage Trichomonas Endometriosis Infertility Genital herpes Abnormal bleeding Other Genital warts Cervical surgery/leep Group B strep HPV: human papilloma virus
6 Name: Allergies Do you have any allergies to medications or foods? Surgical History: Please list any past surgical procedures and dates: Family History Father: Alive and well? Y N If no explain: Mother: Alive and well? Y N If no explain: _ How many pregnancies did your mother have? How many miscarriages? How many times did she give birth? Did she have any C-sections? Siblings: Alive and well? Y N If no explain Please check if you have a family history of the following conditions: Diabetes Twins Hypertension _Down's syndrome Cancer Genetic Disorders Blood Disorder Cystic Fibrosis --Congenital Anomalies Neural Tube defects Current Pregnancy Problems and Exposures: Please check if you've had any ofthese problems in this pregnancy Nausea Constipation Anemia Backache Depression Vomiting Hemorrhoids Fatigue Sciatic nerve pain Anxiety Vaginal Varicose veins Weakness Leg cramps Relationship bleeding issues Uterine Diarrhea Fainting Swelling Family issues crampmg Bladder Heartburn Vaginal discharge Headache Work issues infection Kidney Poor appetite Vaginal infection Dizziness Difficulty infection sleeping Fever Indigestion Pelvic pain Breast pain Other Have you used or been exposed to any of the following during this pregnancy? Prenatal vitamins Nutritional Marijuana Ultrasound supplements Prescription Caffeine Street drugs: co came, Chemicals, fumes, Medication oxycontin, sprays methamphetamine, etc. Over the counter Alcohol Vaccinations Cat litter medications Herbal Medicines Tobacco X-rays Other
7 Name: Y N- Have you had a previous baby with birth defect or mental retardation? Y N - Do you have a history of genetic or inherited conditions or genetic counseling? Y N - Do you have a history of hepatitis? Y N- Do you have a history of IV drug use or blood transfusion? Y N - Do you have a history of a sexual partner who used IV drugs, had bisexual relations or blood transfusions? Y N - Have you had a history of anorexia, bulimia or other eating disorder? Y N - Have you ever been in an abusive relationship, including now, or been abused - physically, emotionally, sexually Do you know where you plan to give birth? Home, hospital, birth center? If no, what information or support do you need to help you in making this decision? How do you feel about this pregnancy? How does your partner feel about this pregnancy? Are there any particular ethnic, cultural or religious preferences for your care that you'd like to discuss? Do you feel you have adequate resources for this pregnancy, i.e. food, shelter, money? Why did you choose to see me? What expectations do you have of me professionally as your midwife?
8 Name: What is your present level of commitment to address any lifestyle issues that may relate to your pregnancy? Rate from 0 to 10, 10 being 1 00% committed 0% % What behavior or lifestyle habits do you currently engage in regularly that you believe are detrimental to your pregnancy? Do you feel you have people in your life that will sincerely and consistently support you during this pregnancy? Many people seek midwifery care because they believe pregnancy and birth to be a normal natural process. As a naturopathic doctor I have knowledge of various nutrients, herbs and homeopathic remedies that may be helpful and supportive of your pregnancy and birth. Would you be interested in suggestions or taking additional supplements during your pregnancy? Thank you for taking the time to complete these many forms. I look forward to providing you with the best possible care. If there is anything else you would like to add at this time please do so here.
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Please review, complete, and return all paperwork included in this packet. If you have any questions or concerns please feel free to contact us at
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