PATIENT INFORMATIONDate: ______________________ Patient Name: _____________________________ Date of Birth: ______________________ Home Address:______________________________________________________________________ Home Phone: _______________________ Cell Phone: ________________________________ Email: _________________________________ Last 4 digits SSN: ____________________ *Race: _______________________________ *Ethnicity: ______________________________*Race and ethnicity are used strictly to provide information necessary to proper care and treatment.

Employer name: _____________________________ Position: ________________________________ Address:____________________________________ Work phone: ___________________________Marital Status: □ Single □ Married □ Separated □ Divorced □ Widowed

How did you find Seasons of Life Obstetrics & Gynecology, PC? (Please check all that apply.) □ Former patient □ Referral from friend or family member□ Print publication: _______________________□ Other Advertisement: _________________ □ Internet Search Engine: _________________ □ Website □ Facebook □ List of Providers from Insurance Company □ Other: ________________________________

SPOUSE/ GUARDIAN INFORMATION Spouse/ Guardian Name: ___________________________ Relationship to Patient: ___________ Date of Birth: ______________________ Cell Phone: _______________________ Employer Name: ______________________ Occupation: __________________________

Updated January 2021

FAMILY PHYSICIAN/ PCP INFORMATIONPractice Name: _________________________________________________________________ Physician Name: ________________________________________________________________ Office Address: _________________________________________________________________ Office Phone: _____________________

PHARMACY INFORMATIONPrimary Pharmacy: ________________ Secondary Pharmacy: _________________ Address: __________________________ Address: ______________________________ ___________________________________ ______________________________________ Phone: ___________________________ Phone: _______________________________

MEDICATIONS: (Please list current medication, dose, and frequency.)

_______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ALLERGIES: (Please list any medications, latex, or other allergies followed by reaction.)

_______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________

PATIENT HEALTH HISTORYUpdated January 2021

Gynecologic and Genitourinary Problems (Please check all that apply.) □ Heavy periods □ Frequent periods □ Absent or infrequent periods □ Cramps □ Abnormal Pap □ Vaginal discharge □ Vaginal itching □ Vaginal dryness □ Pelvic Pain □ Endometriosis □ Ovarian cysts □ Fibroids □ Uterine polyps □ Premenstrual symptoms □ Bleeding with intercourse □ Pain with intercourse □ Sexual problems □ Infertility □ Pelvic organ prolapse □ Frequent bladder infections □ Urine leakage □ Urinary frequency □ Urinary urgency □ Osteoporosis □ Abnormal Mammogram □Breast lump □ Breast pain □ Nipple discharge □ Hot flashes □ Mood changes □ Postmenopausal bleeding □ Other: ____________________________________________________________________________ PAST MEDICAL HISTORY (Please check all that apply.) □ Diabetes □ High Blood Pressure □ Heart Disease □ Stroke □ Cancer □ Seizures □ Thyroid Disease □ High Cholesterol □ Asthma □ Anemia □ Blood Clots □ Kidney Disease □ Liver Disease □ Gastrointestinal Disorders □ Eating Disorder □ Depression □ Anxiety □ Psychiatric Disorder □ Headaches □ Other: _____________________________________________________________________________

GYNECOLOGIC HISTORY Length of each period _____ days Frequency: _____________________Do you get a monthly period Flow: __________________________Age of first period _____ yearsCurrent method of birth control: ___________________Post Menopausal? YES_______ NO______1st day of last period__________________________Date of last Pap smear: ______________________ □ Normal □ Abnormal Date of last Colonoscopy ____________________ □ Normal □ AbnormalCurrent method of birth control: ___________________________________________________

Desired method of birth control: ____________________________________________________

Hormone replacement therapy? YES_______ NO______

Are you sexually active? YES_______ NO______

Do you have any sexual problems? YES_______ NO______

Date of last bone density scan: _______________ □ Normal □ Abnormal

Date of last mammogram: ____________________ □ Normal □ Abnormal

OBSTETRIC HISTORY Have you ever been pregnant? □ Yes □ No (If No, please skip to next section.)

Updated January 2021

How many times have you been pregnant? ____ How many living children do you have? ____

Vaginal Deliveries (Dates): __________________________________________________________

Cesarean Deliveries (Dates): ________________________________________________________ Preterm Deliveries (Dates): __________________________________________________________Miscarriages (Dates): _______________________________________________________________ Abortions (Dates): __________________________________________________________________Ectopic Pregnancies (Dates): _______________________________________________________

Obstetrical Complications (Please check all that apply.)

□ Diabetes in pregnancy □ Pre-eclampsia □ Eclampsia □ Stillbirth □ Fetal anomaly □ Poor fetal growth (IUGR) □ Excessive fetal growth (Macrosomia)

□ Placental abruption □ Placenta previa (placenta covers the cervical os) □ Postpartum hemorrhage □ Preterm labor □ Premature delivery □ Twin pregnancy □ Triplet or higher pregnancy □ Low amniotic fluid (Oligohydramnios) □ High amniotic fluid (Polyhydramnios) □ Cervical insufficiency or Loss of second-trimester pregnancy □ Recurrent miscarriage □ Other: ______________________________________________________________________________

FAMILY HISTORY: □ Check here if adopted or unknown family history. Disease Family Member(s) Age at Diagnosis *Please specify maternal (mother’s side) or paternal (father’s side)

□ Breast Cancer ___________________________ ________________ □ Gynecologic Cancer

___________________________ ________________ (Uterine, Ovarian, Cervical, etc.)

□ Other Cancers (list type) ___________________________ ________________ (Colon, Melanoma, Lung, etc.)

□ Heart Disease ___________________________ ________________ □ Hypertension ___________________________ ________________ □ High Cholesterol or Triglycerides__________________________

_________________

Updated January 2021

□ Diabetes ___________________________ ________________ □ Osteoporosis, Bone Fractures___________________________ ________________ □ Blood Clots ___________________________ ________________ □ Alzheimer’s Disease ___________________________ ________________

SOCIAL HISTORY: Tobacco use? □ Yes □ No If Yes, how many cigarettes per day? _________ How long? _____________________ Occupation: __________________________________________________________________Highest level of education: ____________________________________________________What is your stress level? □ Low □ Medium □ HighDo you exercise regularly? □ None □ Occasional □ Moderate □ HeavyMarital Status:

Alcohol use? □ Yes □ No If Yes, how many drinks per week? ______ Caffeine? □ None □ Occasional □ Moderate □ Heavy Drug use? □ Yes □ No If Yes, what type? __________________ How often? _________ Are you sexually active? □ Yes □ No If yes, how many partners? _______________Do you have unprotected sex? □ Never □ Sometimes □ AlwaysHave you ever been physically or sexually abused? □ Yes □ No Are you being abused now? □ Yes □ No PAST SURGERIES and HOSPITALIZATIONS: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________Gynecologic Surgical History (Please list year and procedure) _____________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________Sexually Transmitted Infection History (Please check all that apply)

□ Gonorrhea □ Chlamydia □ Pelvic Inflammatory Disease (PID) □ HIV □ Herpes □ Trichomonas □ Syphilis □ Genital warts □ HPV □ Hepatitis B □ Hepatitis C

VACCINES: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________QUESTIONS: Do you have any particular concerns, needs, questions or comments?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Updated January 2021

________________________________________________________________________________________________________________________________________________________________________________

PATIENT APPOINTMENT POLICIESWe value your time as a patient, and respectfully ask you to do the same with our providers and other patients in our practice. Being able to maintain an on-time daily schedule is a high priority at Seasons of Life, but at times, unforeseen issues or emergencies may be a valid reason that we are running behind schedule. As a courtesy, our system will deliver a reminder call prior to your appointment with us, but ultimately the responsibility falls to you to be on time for your appointment. Please understand that when you fail to provide adequate notice when cancelling an appointment, fail to show up, or arrive late for your scheduled appointment, you inconvenience our other patients and cause the office to run behind schedule. In order to protect our patients’ time and our office time, we will be enforcing the following policies:We respectfully require that you provide no less than 24 hours’ notice for all cancellations, unless an unavoidable circumstance prohibits your arrival, i.e. auto accident or medical emergency. There will be a $30 charge for any inappropriately cancelled appointments and no shows. This charge must be paid in full before another appointment can be scheduled at Seasons of Life. If you arrive more than 10 minutes late for your scheduled appointment and the schedule does not have an immediate opening, we will have to reschedule your appointment for the next available, whether it is that same day or another day. Repeated cancellation or no shows may be cause for your termination from our practice. We will always strive to honor your appointment at the time it is scheduled. However, if an unforeseen delay due to a medical emergency occurs that our doctors are obligated to handle, we will offer you the option of waiting or rescheduling your appointment.

I have read and fully understand the policies above. Patient Name (printed): ________________________________________________Patient Signature: ______________________________________________________Date: _______________________ Updated January 2021

Witness: _________________________________________

AUTHORIZATION FOR RELEASE OF INFORMATION & CONSENT TO USE & DISCLOSE HEALTH INFORMATION

This acknowledgement of notice and consent authorizes Seasons of Life Obstetrics & Gynecology, PC to use and disclose health information about you for treatment,

payment and healthcare operations purposes. Please read completely before signing your consent.INSURANCE AUTHORIZATION AND ASSIGNMENT

I authorize Seasons of Life Obstetrics & Gynecology, PC to apply for benefits on my behalf. I request that payment be made directly to Seasons of Life Obstetrics & Gynecology, PC. I understand that it is my responsibility to pay any balances not paid by insurance. I understand that co-pays are due at the time of service. I certify that the information I have reported with regard to my insurance coverage is correct. I authorize the release of medical information necessary to process this claim. I permit a copy of this authorization to be used in place of the original. Either my insurance company or I may revoke this authorization at any time in writing. I understand that if my insurance company requires an authorized referral, I must present it prior to my visit. I acknowledge that if I do not provide a referral at the time of service, I will be considered a “self-pay” patient and will be responsible for the PAYMENT IN FULL for all charges incurred that day.

CONSENT TO RETRIEVE MEDICAL INFORMATION

As a patient in our practice, I give consent to Seasons of Life Obstetrics & Gynecology, PC to retrieve and use my medication history from SureScripts, an electronic prescriptions network. This is an electronic way for our office to access patient prescription benefit information and patient medication history, and route prescriptions to a patient’s pharmacy of choice. We can only retrieve medication history from offices who support SureScripts.

NOTICE OF PRIVACY PRACTICES

Seasons of Life Obstetrics & Gynecology, PC has a Notice of Privacy Practices which describes how we may use and disclose your protected health information and how you can access and exercise your rights concerning your personal health information. You may review our current notice prior to signing this acknowledgement and consent. Seasons of Life Obstetrics & Gynecology, PC reserves the right to change our Notice of Privacy Practices and to make the terms of any change effective for all protected health information that we maintain, including information created or obtained prior to the date of the effective date of the change.

Updated January 2021

ACKNOWLEDGEMENT & CONSENT

I have received the Notice of Privacy Practices for Seasons of Life Obstetrics & Gynecology, PC. Seasons of Life Obstetrics & Gynecology, PC is authorized to use and disclose my personal health information for treatment, payment, and healthcare operations purposes consistent with the policies stated above and its Notice of Privacy Practices.

Patient Name (printed): __________________________________________________________Patient/ Guardian Signature: ________________________________ Date: ______________ Relationship to Patient: _________________________________

Updated January 2021

COMMUNICATION CONSENTIt is the office policy of Seasons of Life Obstetrics & Gynecology, PC and its staff not to release confidential and/or unauthorized information by phone, answering machine, voicemail, etc. unless otherwise permitted. When returning telephone calls, we will not leave a message if the name or phone number on the recorded message cannot adequately identify the residence of the patient. Furthermore, patient information will not be disclosed to any unauthorized person who may answer our call.I authorize Seasons of Life Obstetrics & Gynecology, PC and its staff to leave medical information pertaining to my care by the following methods only and will assume responsibility to notify them whenever this information changes. Please check all that apply.

Home Phone: □ Yes □ No Home Voicemail: □ Yes □ No Work Phone: □ Yes □ No Work Voicemail: □ Yes □ No Cell Phone: □ Yes □ No Cell Voicemail: □ Yes □ No Email: □ Yes □ No Fax Medical Records: □ Yes □ No I authorize Seasons of Life Obstetrics & Gynecology, PC to release medical information to the following individuals in my absence. Please list names of authorized individuals.

Spouse: ___________________________________ □ Yes □ No Parent: ____________________________________ □ Yes □ No Other (please list name and relationship to patient):

__________________________________________ □ Yes □ No __________________________________________ □ Yes □ No

Patient Name (printed): __________________________________________________________Patient/ Guardian Signature: ______________________________ Date: ________________

Relationship to Patient: _________________________________

Updated January 2021