Consultation with Ultrasound Consultation Only Fetal Non-Stress Test BPP Nuchal Translucency Routine Ultrasound Only Amniocentesis



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Transcription:

Appointment Information: Desired Appointment Type: (Check all that apply) Consultation with Ultrasound Consultation Only Fetal Non-Stress Test BPP Nuchal Translucency Routine Ultrasound Only Amniocentesis Timeframe: Special Appointment Needs: Demographic Information: Patient Name: DOB: Address: City: ST: ZIP: Home: Cell: Work: Other Ph: Best time to call: Preferred Number to call: EDC: Gravida: Para: DX: Referring Physician: Phone: Fax: Contact Name: Phone: Insurance Information: (Please complete all below, or attach a copy of the patient s insurance card.) Insurance Company: Address: City: ST: ZIP: Policyholder: Policy Number: Policyholder s DOB: Group Number: Patient Medical Records Needed: All current pregnancy prenatal records including: Labs Previous pregnancy records (if pertinent) Ultrasounds Maternal-Fetal Medicine Forms Supplied: (Check all that apply) Appointment Sheet with map Health History Form Introduction to Maternal-Fetal Medicine Letter Thank you for your referral. Once we receive this completed form, we will contact your patient for an appointment with Maternal-Fetal Medicine. We will also send you a fax with your patient s appointment date and time. Darren M. Farley, M.D., F.A.C.O.G. 3232 East Murdock, 2 nd Floor Wichita, KS 67208 P (316) 239-2850 F (316) 239-2852

Dear Patient and Family, Welcome to Associates in Women s Health, P.A. Dr. Darren Farley is a board certified, Obstetrician/Gynecologist who has completed his fellowship in Maternal-Fetal Medicine. The ultrasonographers working with Dr. Farley each have more than 20 years of ultrasound experience, and each have 10-15+ years, of experience working with maternal-fetal patients. Maternal-Fetal Medicine, also referred to as perinatology, is the study and care of Complicated and High Risk Pregnancies. We see and treat patients for a wide variety of reasons. Some include: Maternal conditions: o Diabetes o High blood pressure o Lupus Fetal Conditions: o Abnormal pregnancy screening results o Abnormal ultrasound findings Twins, triplets or more Amniocentesis Family history of abnormalities, including genetic abnormalities Pre-pregnancy counseling Your personal physician will continue with your pregnancy care and the delivery of your baby. If you do not have an Obstetrician or Family Physician in the Wichita area and need to deliver your baby here, Dr. Farley will arrange for an Obstetrician to assume your care here in Wichita. At your first visit, Dr. Farley and his staff will perform a detailed review of your past and present medical history. Depending on the reason for your visit, you may receive an ultrasound and/or other fetal testing. Some of the testing will be determined by the findings of this visit. You should plan to spend about two (2) hours here at your first visit. All results that are available will be discussed with you at that time. Dr. Farley will also discuss those results and a plan of care, if indicated, with your personal physician. It is not unusual for you to see Dr. Farley for only one visit, however, at anytime your doctor may refer you for another appointment, ultrasound or other testing. Most likely, you and your family will have questions. Please feel free to write them down and bring them with you. Our goal is to keep you completely informed and educated about the circumstances surrounding your visit with us. We are looking forward to assisting you and your doctor during this pregnancy. If you have questions regarding your up-coming visit, please call and talk with one of our staff. The telephone number is 316-239- 2850. Sincerely, Associates in Women s Health, P.A. Darren M. Farley, M.D., F.A.C.O.G. 3232 East Murdock, 2 nd Floor Wichita, KS 67208 P (316) 239-2850 F (316) 239-2852

Welcome to Maternal-Fetal Medicine, Your personal physician has requested a comprehensive evaluation of you and your unborn baby. This evaluation may consist of any one or more of the following: detailed pregnancy ultrasound, maternal-fetal consultation and antenatal fetal testing. You and your baby deserve our mutual undivided attention, so we respectfully request that your appointment be an ADULT ONLY visit. You should plan to be in our office as long as 2 hours, although your individual appointment needs will dictate the length of your visit. You are welcome to bring 2 or 3 additional adults to be with you during your appointment. Any children accompanying you will need adult supervision while remaining in the waiting room for the duration of your appointment or in the event any procedures, such as amniocentesis, are necessary. If you are unable to obtain adult supervision for your children, you will be asked to reschedule your appointment. We look forward to seeing you on: Day Date Time (Please arrive 20 minutes prior to your scheduled appointment time.) Videotaping or photography is not allowed. Patients having a sonogram will be given a CD or photographs of their baby s images. Darren M. Farley, M.D., F.A.C.O.G. 3232 East Murdock, 2 nd Floor Wichita, KS 67208 P (316) 239-2850 F (316) 239-2852

Reason For Visit: Pharmacy #1: Pharmacy #2: HEALTH HISTORY QUESTIONNAIRE Name_ Birthdate Primary Care Physician: City: Location: City: Location: Age when you started having periods: Date of Last Menstrual Period: Number of pregnancies Full term deliveries Pre term deliveries /s Living Children Medication allergies and reaction: Please include all over the counter medications and prescription medications. Medication Dose/Strength # of pills/amt times/day Medical History Please check if you have or have ever been diagnosed with any of the following conditions: Anemia Heartburn/Reflux Arthritis Hepatitis (type ) Asthma High Blood Pressure Blood Clot Irritable Bowel Syndrome Blood Transfusion Kidney Stones Chronic Urinary Infection Lupus Crohn s Disease Migraines Diabetes (type ) Psychiatric Disorder Diverticulitis Bipolar Disorder Depression Elevated Cholesterol Obsessive/Compulsive Schizophrenia Epilepsy Stroke Fibromyalgia Thyroid Disorder Heart Disease Hyperthyroid Hypothyroid Angina Goiter Graves Disease Congestive heart failure _Other Coronary artery disease Mitral valve prolapse

GYN PROBLEMS Abnormal Pap Smears Bartholin Cyst Breast Cancer Breast Lump Cervical Cancer Cervical Dysplasia Chronic Vaginal Infections Chronic Pelvic Pain Endometrial Hyperplasia Endometriosis Fibrocystic Breast Habitual Aborter(> 3 s) Infertility Ovarian Cancer Ovarian Cyst Heavy Bleeding Irregular Period Lichen Sclerosis Pelvic Inflammatory Disease Prolapse Sexually Transmitted Disease Chlamydia Genital Warts Gonorrhea Herpes Trichomonas Urinary Incontinence Uterine Cancer Uterine Fibroids Other SURGICAL HISTORY Have you ever had any of the following surgeries and if so when. Arthroscopy ( ) Appendectomy/Appendix Cataracts Cardiac Surgery ( ) Cystoscopy Gallbladder Removed Hip Replacement R or L Knee Replacement R or L Age Yr Sinus Surgery Tonsillectomy Tonsillectomy/Adenoids Tubes in ears Wisdom Tooth Extraction Age Yr GYN SURGICAL HISTORY Breast Augmentation Breast Biopsy Breast Reduction Cesarean Section Cervical Procedures Cone Biopsy Cryo Laser LEEP Colposcopy D & C Age Yr Endometrial Ablation Hysteroscopy Hysterectomy Abd / Vag Laparoscopy Laparotomy Mastectomy R / L / B Ovaries Removed R / L / B Tubal Ligation Age Yr

OBSTETRICAL HISTORY Please fill out for each pregnancy even if it was a miscarriage or abortion. If you ve had a tubal ligation, hysterectomy, or are over the age of 50, only date and type of delivery are necessary. Preg # Type of Delivery Date MM/YY Baby Name Gestational Age Wt Sex Hospital Doctor Complications FAMILY MEDICAL HISTORY Please check if anyone in your immediate family has been diagnosed or treated for the following: Adopted Mother Father Sister Brother Daughter Son Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Breast Cancer Colon Cancer Ovarian Cancer Diabetes Hypertension Stroke Heart Disease Thyroid Disorder Osteoporosis Epilepsy Kidney Problems Lung Disease

SOCIAL HISTORY Marital Status: Married Divorced Legally Separated Single Widowed Engaged Domestic Partner Occupation: Unemployed Disabled Place of Employment: Race: African-American Asian Caucasian Hispanic Other: Diet: Diabetic Healthy High Fat Low Fat Low Sodium Junk Food Exercise: 2-3x/week 3-4x/week Daily Never Occasional Rarely Tobacco Use: No Yes Former Type: Amt/day: #Years: Year Quit: Alcohol Use: No Yes Former Frequency: Year Quit: Illicit Drug Use: No Yes Former Type: #Years: Year Quit: Have you ever had chicken pox? Yes No I had the vaccine Unknown Do you have cats? No Indoor Only Indoor/Outdoor Outdoor Father of Baby: Father of Baby s Race: African-American Asian Caucasian Hispanic Other: HEALTH MAINTENANCE Date of Last Pap Smear: Result: Chicken Pox Status: I have had chicken pox I have had the chicken pox vaccine I have had the vaccine and chicken pox I have had neither the vaccine nor chicken pox Hepatitis B: I have received the entire Hepatitis B vaccination series I have part of the Hepatitis B vaccination series I have not received the Hepatitis B vaccination series Flu Vaccine: I have received the Flu vaccine this year. Pneumonia Vaccine: I have received a vaccine for Pneumonia. Year of Last Tetanus Vaccine:

GENETIC HISTORY Please check if anyone in your immediate family or the baby s father s family has been diagnosed or treated for the following: Abbreviations: MOB (Mother of the Baby) FOB (Father of the Baby) Previous Child MOB MOB, Mother MOB, Father MOB, Sister MOB, Brother FOB FOB, Mother FOB, Father FOB, Sister FOB, Brother Thalassemia Neural Tube Defect Congenital Heart Defect Down Syndrome Tay-Sachs Canavan Disease Sickle Cell Hemophilia Muscular Dystrophy Cystic Fibrosis Mental Retardation Autism PKU Recurrent Miscarrriage Stillborn Infant Darren M. Farley, M.D., F.A.C.O.G. 3232 East Murdock, 2 nd Floor Wichita, KS 67208 P (316) 239-2850 F (316) 239-2852

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