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 Last Name
Primer Nombre __________________________________ Apellido _________________________________________
Social Security Number Date of Birth Sex Female Male
# de Seguro Social _______ - ______ - _______ Fecha de Nacimiento ____ / ____ / ____ Sexo Femenio 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 No mail
Si, sin direccion 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 No calls Yes, saying doctor’s office Yes, saying it’s a friend
Si, diciendo Planned Parenthood Ninguna llamadas Si, diciendo oficina de doctor Si, diciendo que es una amiga
Please check all that apply
Por favor marque todo que aplica
Student Yes No Highest grade of school you have completed
Estudiante Si No Grado mas alto que ha completado en la escuela ________
Race Black or African American Asian Multiracial Native American Pacific Islander White
Raza Moreno o Americano Africano Asiatico Multiracial Americano Nativo Isleno Pacifico Blanco
Hispanic Yes, Hispanic or Latin No, not Hispanic or Latin Unknown
Hispano Si, Hispano o Latino No Hispano o Latino No sabes
Language English Other Interpreter Needed
Idioma Ingles Otro ________________________ Necesito un Interprete
How did you hear about us? Family or Friend Internet Other Advertising Other Doctor’s Office Yellow Pages
Como escucho acerca de nosotros? Familia o Amiga Internet Otro publicidad Otro oficina de Doctόr Yellow Pages
Household income Yearly Monthly Weekly
Ingreso de la casa $_________.___ Anual Mensual Semanal
Family Size How many are children
Cuantos son en tu familia ________ Cuantos son niño(s) ________
.
G:\Medical\Forms\History\MEDI160 New Patient Registration Form 020212.docx
G:\Public and Community Affairs Volunteers\Casey Olesko\Forms Online\2014\Pregnancy Test.doc Reorder # 0517418
Planned Parenthood Association of the Mercer Area
PREGNANCY EVALUATION MEDICAL HISTORY FORM
Date: __________________
Name: ______________________
Chart #: ______________________
Date of Birth: ______________________
Brief Medical History
1. When was the first day of your last normal menstrual period (date)? _______________________
a. This period was: on time early late
b. The amount of bleeding was: normal lighter heavier
c. Are your cycles: regular irregular
2. Please check off any symptoms that you have noticed recently:
Nausea/Vomiting Excess fatigue Swelling in abdomen Increased Urination Fever or chills
Breast tenderness/swelling Severe or persistent abdominal pain Shoulder pain Spotting or Bleeding
3. Have you had unprotected sex since your last period? No Yes If yes, last date:____________
4. Are you currently using a method of birth control? No Yes If yes, what type:_______________
5. Were you planning a pregnancy at this time? No Yes
6. Have you been pregnant before? No Yes If yes, please indicate the dates of:
Live births ______________________ Miscarriages _______________________
Abortions ____________________ Tubal pregnancies ________________
7. Please list current or continuing medical problems: ______________________________________
8. Have you ever had: gonorrhea or Chlamydia, an infection in your uterus/tubes (PID), or an infection after an abortion
or delivery? No Yes If yes, please explain:
_______________________________________________________________________
9. Please list any medications or vitamins you are currently using _______________________________.
10. Are you taking any street drugs? No Yes If yes, which ones? _______________________
11. Have you taken any medicines or drugs in the last 24 hours? No Yes If yes, which ones?
_________________________________________________________________________________
Patient Signature: ______________________________________________________________
Lab Notes
Date: _________________ Type of Test: ________________________________________________
Result: ________________ Technician Signature and Title: ___________________________________
G:\Public and Community Affairs Volunteers\Casey Olesko\Forms Online\2014\Pregnancy Test.doc Reorder # 0517418
Name: __________________
Chart #: __________________
Date of Birth: __________________
Counseling Notes
Folic Acid Information given Folic Acid Given 400mg or 800mg or RX
Patient offered Urine GC/Chlamydia testing accepted declined
Trust In Yourself Information Sheet Given to patient
Safety Card given
Positive Test
Number of Weeks since LMP: ________________
Continuing Pregnancy
_____Folic Acid Information Provided
_____Patient given Folic Acid 400mg or 800mg or RX
_____Patient reminded of need for pelvic exam within 30 days
_____Explained risk of drugs, alcohol, smoking, and X-rays
_____Patient offered referral for prenatal care elsewhere. Referred to __________________________
_____Patient undecided about where to access care.
Three referrals provided: 1.____________________ 2._____________________ 3.____________________
_____Patient interested in adoption. Adoption information and referrals provided.
Abortion
_____Patient reminded of the need for pelvic confirmation within 7 days
_____Surgical and Medical Abortion options explained to patient
_____Patient requested referral for termination of pregnancy. Referred to____________________________
_____Patient undecided about where to access care
Three referrals provided: 1.____________________ 2._____________________ 3.____________________
_____Birth Control and STI Information provided
How is the client feeling about her decision?
___Confident and clear about decision to have the abortion
_____Sad / angry / afraid / ambivalent feelings but clear about decision
_____Support System assessed
_____Referred for additional Counseling.
Undecided
_____Patient referred for an additional Options Counseling session. Referred to:_________________
_____Patient reminded the importance of making a decision within the appropriate time frame
_____Patient provided with PPAMA phone number and counselor name.
_____Patient support system assessed
_____Folic Acid Information Provided
*If patient is under <18 years old, will they need assistance disclosing this pregnancy to a parent/guardian?
No Yes
Negative Test
Desires Pregnancy
_____Natural Family Planning information provided
_____Folic Acid Information Provided
Does Not Desire Pregnancy
____Contraceptive information provided and discussed with patient
____STI information provided and discussed, offered Urine GC/Chlamydia testing accepted declined
____Patient explained the need for a repeat test in 7-10 days if normal menses does not ensue
____Patient offered a family planning visit if not currently using birth control
____Patient offered condoms and spermicide
____Patient selected other provider from whom she plans to seek follow-up care
Signature and Title: ___________________________________________________________
