medical history form for ecps with a deferred exam

medical history form for ecps with a deferred exam

New Patient Registration Form
Regestaciόn Para Paciente Nueva
Patient # _____________
Please complete the following form. All the information is confidential.
Por favor complete la hoja seguida. Toda la informaciόn es confidential.
First Name
Primer Nombre __________________________________
Last Name
Apellido _________________________________________
Social Security Number
# de Seguro Social
_______ - ______ - _______
Date of Birth
Fecha de Nacimiento ____ / ____ / ____
Sex
Sexo
Female
Femenio
Male
Masculino
Address
County
Direcciόn _______________________________________ Condado _________________________
City
State
Zip
Ciudad _________________________ Estado _________ Cόdigo __________________________
What is the best phone number for us to reach you during the day?
Cuál es el major número de telefono mara que poclamos comunicar con usted durante el día? _____________________________________
Emergency contact phone number
Numero de contacto de emergencia ___________________________
Emergency contact name
Relationship to you
Nombre del contacto de emergencia ___________________________ Relaciόn con usted
____________
Note: you MUST check YES for at least one mail or phone option
Please check if you can receive mail from us (PPAMA)
Por favor, marque si es puede recibir correo de nosotros (PPAMA)
Yes, no return address
Si, sin direccion
No mail
Ninguna respeta
Please check one of the four ways you want to receive phone calls from us (PPAMA)
Por favor marque una de las cuartro maneras que tu querre recibir corresponda de nosotros (PPAMA)
Yes, saying Planned Parenthood
Si, diciendo Planned Parenthood
No calls
Ninguna llamadas
Yes, saying doctor’s office
Si, diciendo oficina de doctor
Yes, saying it’s a friend
Si, diciendo que es una amiga
Please check all that apply
Por favor marque todo que aplica
Student
Estudiante
Race
Raza
Yes
Si
No
No
Black or African American
Moreno o Americano Africano
Highest grade of school you have completed
Grado mas alto que ha completado en la escuela ________
Asian
Asiatico
Hispanic
Hispano
Yes, Hispanic or Latin
Si, Hispano o Latino
Language
Idioma
English
Ingles
Multiracial
Multiracial
Native American
Americano Nativo
Pacific Islander
Isleno Pacifico
No, not Hispanic or Latin
No Hispano o Latino
Other
Otro ________________________
Internet
Internet
White
Blanco
Unknown
No sabes
Interpreter Needed
Necesito un Interprete
Other Advertising
Otro publicidad
How did you hear about us?
Como escucho acerca de nosotros?
Family or Friend
Familia o Amiga
Household income
Ingreso de la casa $_________.___
Yearly
Anual
Family Size
Cuantos son en tu familia ________
.
How many are children
Cuantos son niño(s)
________
Monthly
Mensual
G:\Medical\Forms\History\MEDI160 New Patient Registration Form 020212.docx
Other Doctor’s Office
Otro oficina de Doctόr
Weekly
Semanal
Yellow Pages
Yellow Pages
Planned Parenthood Association of the Mercer Area
MEDICAL HISTORY FORM FOR ECPS WITH A DEFERRED EXAM
Date:_______________________
Name: _______________________
Chart #: _______________________
Date of Birth: ______________________
Brief Medical History
Have you ever had:
Stroke?
Blood Clots?
Heart attack or chest pains?
Cancer?
Liver tumor or disease?
Diabetes?
Seizures?
High blood pressure?
High cholesterol?
Bad headaches?
Breast cancer or lumps in your breast?
Serious illness?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
Are you over 35?
Yes
Do you smoke?
Yes
Has a parent, brother or sister had a heart attack before age 55? Yes
No
No
No
Current birth control method _______________________________
Have you had sex without birth control since your last period?
Yes
If yes………………………………Date_______ Time_______
Did anyone force you to have sex?
Yes
Date of last menstrual period __________
Was it a normal period?
Yes
Have your periods been abnormal or irregular lately?
Yes
No
No
No
No
If yes, describe _____________________________________________________
Do you think you are pregnant now?
Yes No
Are you nursing a baby?
Yes No
If pregnant before, please list dates of:
Live Births _______ Abortions _______ Ectopics _______ Miscarriages _______ Other _______
General Health Questions
When was your last physical exam?
_________
Was it normal?
When was your last Pap smear?
_________
Was it normal?
When was your last breast exam?
_________
Was it normal?
When was your last mammogram?
_________
Was it normal?
Do you have any abnormal or unusual vaginal discharge?
Have you had a change of sexual partners in the last 6 months?
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Patient Signature: _______________________________ Date: _______________________
Name: _______________________
Chart #: _______________________
Date of Birth: ______________________
Assessment
Weight _______
Blood Pressure _______________
If Indicated, laboratory test result:
Type of Pregnancy Test: _________________
Result: _________
GC/Chlamydia Testing done: Yes
Result: _________
No
□Yes □ No
Patient stated that she wants Emergency Contraceptive Pills (ECPs).
□Yes
□Yes
□Yes
□Yes
□ No
□ No
□ No
□ No
□Yes
□Yes
□Yes
□Yes
□ No
□ No
□ No
□ No
Patient was told about available options to ECPs.
Information on contraceptive methods given.
Patient was counseled per PP protocol regarding ECP
Patient was given the Client Information for Informed Consent (CIIC): ECPs., with
instructions for use completed on form.
Complete the Request for Medical Services Method Specific form, signature obtained
Patient appropriate candidate for ECPs
ECP given
Safety Card given.
Notes:
Staff Signature: ___________________________________________ Date: _________________
ECP ORDER:
□ Ulipristal acetate # 1 Tab □ (1) tab PO now □ Prophylactic PRN w/in 120 hrs of unprotected IC Refill x ____ Rx given □
□ Plan B #2 Tabs □ (2) tabs PO now □ Prophylactic PRN w/in 120 hrs unprotected IC Refill x____ Rx given □
□ Plan B #2 Tabs □ (1) tab PO now (1) tab in 12 hours □ Prophylactic PRN w/in 120 hrs unprotected IC
Refill x____ Rx given □
□ Other (directions and prophylaxis regime to be written here.)
Clinician Signature
________________________
Date
 New Patient Packet of Information given
Client to return: _________________________
Staff Signature: _________________________ Date ________________________
G:\Public and Community Affairs Volunteers\Casey Olesko\Forms Online\2014\Emergency Contraception.doc
Reorder # 06210123