On the day of your appointment, please be sure to bring:
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- Priscilla Norton
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1 Welcome to Union OB/GYN Please complete and sign the enclosed papers and bring them with you to your scheduled appointment on:. Please be sure to fill out the Patient Intake form in its entirety, including: name, date of birth and Social Security number on each page as well as allergies to medications or latex On the day of your appointment, please be sure to bring: Insurance card Photo I.D. Co-payment due A list of your current medications In order to minimize delays for you and other patients, failure to have paperwork completed will result in your appointment being rescheduled. If you do not show for your first visit, you will not be rescheduled. Please call us with any questions or concerns. Thank you for giving us this opportunity to serve you. Union OB/GYN Sarah A. Barber, D.O. and staff 420 S. James St. Suite C, Dover, Ohio (330) You may visit our website at:
2 UNION OB/GYN SARAH BARBER, D.O. PATIENT INTAKE HISTORY FOR OFFICE USE ONLY NEW PATIENT ESTABLISHED PATIENT CONSULTATION REPORT SENT. PATIENT NAME: BIRTH DATE: SS #: DATE: ADDRESS CITY: STATE/ZIP: HOME TELEPHONE: ( ) WORK TELEPHONE: ( ) EMPLOYER: INSURANCE: POLICY NO.: NAME YOU WOULD LIKE US TO USE: NAME OF SPOUSE/PARTNER: NAME OF INSURED: BIRTH DATE: SS #: EMERGENCY CONTACT: RELATIONSHIP: HOME TELEPHONE: ( ) WORK TELEPHONE: ( ) PHARMACY LOCAL: MAIL ORDER: WHY HAVE YOU COME TO THE OFFICE TODAY? REFERRED BY: IF YOU ARE HERE FOR AN ANNUAL EXAMINATION IS THIS A PRIMARY CARE VISIT OR GYNECOLOGY ONLY IS THIS A NEW PROBLEM? PLEASE DESCRIBE YOUR PROBLEM, INCLUDING WHERE IT IS, HOW SEVERE IT IS, AND HOW LONG IT HAS LASTED. GYNECOLOGIC HISTORY AGE PERIODS BEGAN: LAST MENSTRUAL PERIOD: DAYS BETWEEN PERIODS HAVE YOU EVER HAD SEX? ARE YOU CURRENTLY SEXUALLY ACTIVE? LENGTH OF FLOW OF SEXUAL PARTNERS (LIFETIME): SEXUAL PARTNERS ARE MEN WOMEN BOTH PRESENT METHOD OF BIRTH CONTROL: HAVE YOU EVER USED AN INTRAUTERINE DEVICE (IUD) OR BIRTH CONTROL PILLS? IF YES, FOR HOW LONG? WHEN WAS YOUR LAST PAP TEST? WHAT WAS THE RESULT? HAVE YOU EVER HAD AN ABNORMAL PAP TEST? DO YOU DO BREAST SELF-EXAMINATIONS? HAVE YOU EVER HAD A SEXUALLY TRANSMITTED DISEASE (GONORRHEA, CHLAMYDIA, ETC)? WHEN WAS YOUR LAST MAMMOGRAM? HAS IT EVER BEEN ABNORMAL? WHEN WAS YOUR LAST DEXA OR BONE DENSITY TEST? WHEN WAS YOUR LAST COLONOSCOPY? Form No Q (4/11) Union Hospital, Dover, OH Page 1 of 4
3 PATIENT INTAKE HISTORY (Continued) PATIENT NAME: BIRTH DATE: OBSTETRIC HISTORY SS #: DATE: PREGNANCIES ABORTIONS MISCARRIAGES PREMATURE BIRTHS (<37 WEEKS) LIVE BIRTHS LIVING CHILDREN NO. BIRTH DATE WEIGHT AT BIRTH BABY'S SEX WEEKS PREGNANT TYPE OF DELIVERY (VAGINAL, CESAREAN, ETC.) ANY PREGNANCY COMPLICATIONS? HYPERTENSION/HIGH BLOOD PRESSURE PREECLAMPSIA/TOXEMIA ANY HISTORY OF DEPRESSION BEFORE OR AFTER PREGNANCY? NO YES, HOW TREATED CURRENT MEDICATIONS (Including hormones, vitamins, herbs, nonprescription medications) DRUG NAME DOSAGE WHO PRESCRIBED DRUG NAME DOSAGE WHO PRESCRIBED FAMILY HISTORY M: LIVING DECEASED-CAUSE: AGE: FATHER: LIVING DECEASED-CAUSE: AGE: SIBLINGS: LIVING: LIVING: DECEASED: DECEASED: CAUSE(S)/AGE(S): CAUSE(S)/AGE(S): ILLNESS YES WHICH RELATIVE(S) AND AGE OF ONSET STROKE HEART DISEASE BLOOD CLOTS IN LUNGS OR LEGS HIGH BLOOD PRESSURE HIGH CHOLESTEROL OSTEOPOROSIS (WEAK BONES) HEPATITIS HIV/AIDS TUBERCULOSIS BIRTH DEFECTS ALCOHOL OR DRUG PROBLEMS BREAST CANCER COLON CANCER OVARIAN CANCER UTERINE CANCER MENTAL ILLNESS/DEPRESSION ALZHEIMER'S DISEASE Form No Q (5/12) Union Hospital, Dover, OH Page 2 of 4
4 PATIENT INTAKE HISTORY (Continued) PATIENT NAME: BIRTH DATE: SS #: DATE: SOCIAL HISTORY YES NO EVER SMOKED? CURRENT SMOKING: PACKS PER DAY: YEARS: ALCOHOL DRINKS PER DAY: DRUG USE SEAT BELT USE DRINKS PER WEEK: TYPE OF DRINK: REGULAR EXERCISE: HOW LONG AND HOW OFTEN? DAIRY PRODUCT INTAKE AND/OR CALCIUM SUPPLEMENTS DAILY INTAKE: HEALTH HAZARDS AT HOME OR WORK? HAVE YOU BEEN SEXUALLY ABUSED, THREATENED, OR HURT BY ANYONE? DO YOU HAVE AN ADVANCE DIRECTIVE (LIVING WILL?) ARE YOU AN ORGAN DONOR? SEXUAL ORIENTATION: HETEROSEXUAL HOMOSEXUAL PERSONAL PROFILE BISEXUAL MARITAL STATUS: MARRIED LIVING WITH PARTNER SINGLE OF LIVING CHILDREN: OF PEOPLE IN HOUSEHOLD: WIDOWED DIVORCED SCHOOL COMPLETED: HIGH SCHOOL SOME COLLEGE/AA DEGREE COLLEGE GRADUATE DEGREE CURRENT OR MOST RECENT JOB: TRAVEL OUTSIDE THE UNITED STATES: LOCATION(S): PERSONAL PAST HISTORY OF ILLNESSES/DISEASES OPERATIONS/HOSPITALIZATIONS REASON DATE HOSPITAL Form No Q (5/12) Union Hospital, Dover, OH Page 3 of 4
5 PATIENT NAME: BIRTH DATE: SS #: DATE: REVIEW OF SYSTEMS (ROS) 1. CONSTITUTIONAL NEGATIVE WEIGHT LOSS WEIGHT GAIN CHANGE IN WEIGHT FEVER FATIGUE TALLEST HEIGHT 2. EYES NEGATIVE VISION CHANGE GLASSES/CONTACTS 3. EAR, NOSE, AND THROAT NEGATIVE ULCERS SINUSES MOUTH SORES HEADACHE HEARING LOSS DENTAL PROBLEMS 4. CARDIOVASCULAR NEGATIVE CHEST PAIN DIFFICULTY BREATHING ON EXERTION SWELLING IN LEGS RAPID HEART BEAT 5. RESPIRATORY NEGATIVE WHEEZING SHORTNESS OF BREATH COUGHING UP BLOOD COUGH 6. GASTROINTESTINAL NEGATIVE DIARRHEA BLOODY STOOL NAUSEA/VOMITING/INDIGESTION CONSTIPATION FLATULENCE PAIN INVOLUNTARY LOSS OF GAC/STOOL 7. GENITOURINARY NEGATIVE BLOOD IN URINE PAINFUL URINATION URGENCY FREQUENCY INCOMPLETE EMPTYING INCONTINENCE PAINFUL INTERCOURSE ABNORMAL OR PAINFUL PERIODS PMS ABNORMAL VAGINAL BLEEDING ABNORMAL VAGINAL DISCHARGE 8. MUSCULOSKELETAL NEGATIVE MUSCLE WEAKNESS MUSCLE OR JOINT PAIN 9a. SKIN NEGATIVE RASH DRY SKIN MOLES ULCERS SKIN CHANGES 9b. BREAST NEGATIVE DISCHARGE PAIN IN BREAST LUMPS 10. NEUROLOGIC NEGATIVE PASSING OUT SEIZURES TROUBLE WALKING SEVERE MEMORY PROBLEMS NUMBNESS 11. PSYCHIATRIC NEGATIVE DEPRESSION SEVERE ANXIETY CRYING 12. ENDOCRINE NEGATIVE HYPOTHYROID HOT FLASHES HAIR LOSS HEAT/COLD INTOLERANCE HYPERTHYROID 13. HEMATOLOGIC/LYMPHATIC NEGATIVE BRUISES BLEEDING ENLARGED LYMPH NODES/GLANDS 14. ALLERGIC/IMMUNOLOGIC MEDICATIONS (PLEASE LIST) LATEX FORM COMPLETED By: PATIENT OFFICE NURSE PHYSICIAN : SIGNATURE OF PATIENT: DATE REVIEWED BY PHYSICIAN WITH PATIENT: : ANNUAL REVIEW OF HISTORY Form No Q (5/12) Union Hospital, Dover, OH Page 4 of 4
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