Thank you for choosing presidential women’s center

Thank you for choosing Presidential Women’s Center. Please take your time and complete this personal and medical information form completely. If you have any questions you will have an opportunity to speak with someone privately. If there is anything we can do to better serve you during your visit, please inform us and we will do our best to accommodate your needs.
Personal Information
Patient Name:______________________________________________________________________________________ First Address______________________________________City_______________________State_______ Zip____________ Home Phone_______________________ Cell____________________________Work____________________________ S.S.#_______- ______- _______ Date of Birth___________________ Age________ Marital Status_________________ Employer___________________Occupation_____________________Race_____________ Religion________________ How were you referred to our office?________________________ First day of last menstrual period_________________ Emergency contact name___________________________Phone_______________Relationship to you_______________ Person driving you home___________________________Phone _______________Relationship to you______________ Do you have Medicaid?
Reproductive History
Number of previous pregnancies____Date of last delivery_________Number of previous abortions____Miscarriages____ Complications with previous pregnancies ___________________________Have you had a cesearian section? Y N Do you have a bicorniated/septated/heart-shaped uterus? Y
Have you ever had the following removed? Right tube______ Left tube_______ Right ovary_______ Left ovary______
Have you ever had an abnormal pap smear? Y N If yes, please give details____________________________
Previous birth control methods:________________________________________________________________________
Surgical History
Please list any surgeries you have had___________________________________________________________________ Have you ever had a local anesthetic with a Novicaine or Xylocaine-like drug (including dental work)? Y Any complications with this medication?_________________________________________________________________ Have you ever had general anesthesia? Y complications?____________________________________ Medical History
►Allergies:________________________________________________________________________________________ ►Medications taken in the last month: Drug_____________________Condition____________________________Dosage__________Last Taken____________ Drug_____________________Condition____________________________Dosage__________Last Taken____________ Drug_____________________Condition____________________________Dosage__________Last Taken____________ Please list all current or recent drug use:__________________________________________________________________ ►Medical Conditions: Have you had any of the following? Please write the age when initially treated. High Blood Pressure________________ Diabetes__________________________ Symptoms of stroke ________________ Heart Murmur______________________ Thrombophlebitis __________________ Are you usually premedicated? Y N Mitral Valve Prolapse________________ Drug Dependency________________ Rhuematic Fever____________________ Epilepsy________________________ Sickle Cell Anemia_________________ HIV______________________________ Sexually Transmitted Infection? Y N Have you been treated for an If yes, please describe________________ emotional disorder? Y N Any medical conditions not listed above_________________________________________________________________ Please indicate if you would like information or assistance with any current or past situation involving sexual, physical or emotional abuse. Y N ______________________________________________________________________ I give the above information freely. It is complete and factual to the best of my knowledge. I understand all information will be kept strictly confidential. Patient __________________________________________________ Date_____________________________________ Witness__________________________________________________Date_____________________________________
Counseling Notes

100 Northpoint Parkway | West Palm Beach, FL 33407


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