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Feminist women's health center

FEMINIST WOMEN’S HEALTH CENTER
CONSENT FOR WELLNESS SERVICES

Please read and sign below if you have an appointment with the nurse practitioner today:
I consent to care and treatment at the Feminist Women's Health Center. I understand that I will be seen by a
nurse practitioner. I also understand that all or part of my accessory health services will be provided by trained
health workers.
If the nurse practitioner finds anything beyond the scope of her practice and/or experience during my
examination, I understand that I may be referred to a physician or other facility. I understand that the nurse
practitioner may consult with a collaborating physician by telephone. I understand that if my situation warrants
a referral to another health care provider, I shall be solely responsible for making those arrangements and for
any fees associated with the healthcare I receive.
___________________________________
Client Signature Date __________________________________ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - CONSENT FOR LABORATORY SERVICES

Please read and sign below if you do not have an appointment with the nurse practitioner today and will
be receiving laboratory testing:
I consent to laboratory testing at the Feminist Women's Health Center. I understand that the interpretation of
any laboratory test results should be made only by a licensed heath care provider as factors unclear to the lay
person may exist.
Because the implications of laboratory testing results can be complex, involving medical, emotional, and social
issues, some results will only be reported to the client in person and so will require a follow up visit. My
laboratory test results and patient information are confidential and may only be released to me. I will need to
sign a request for release of medical records if I want my results mailed or faxed to another health care provider.
Client Signature Date __________________________________ Feminist Women's Health Center
Patient Privacy Notice Authorization
In order to comply with new federal guidelines outlined in the Health Insurance Portability & Accountability Act of 1996 (HIPAA), a Federal law which seeks to protect the privacy of consumers’ healthcare information, we are advising you of your right as to how your medical information may be used. The NOTICE OF PRIVACY PRACTICES located in the waiting rooms of the clinic outlines how personal information about you may be used and how you can get access to this information. If you would like a paper copy of the NOTICE OF PRIVACY PRACTICES please ask and we will be glad to provide you with one. I have also been informed that any payment I make today is part of a global fee structure, which means that it is a discounted fee. Therefore, I may not file insurance at any time for reimbursement in relation to services I receive today. Furthermore, I understand and agree that the receipt for my payment today does not include an itemized statement and that the Feminist Women’s Health Center is not obligated to issue itemized statements for services rendered. **************************************************************** I authorize the Feminist Women's Health Center to communicate medical information pertaining to my care by the methods outlined in the NOTICE OF PRIVACY PRACTICES. I am aware that I may ask for a paper copy of the NOTICE OF PRIVACY PRACTICES at any time. Client signature______________________ Witness_____________________________ Feminist Women’s Health Center
Request for Information
Please help us better serve you by filling out the information below;
the questions on the next two pages are optional.

1. Please indicate your race:

2. Please indicate your primary language:


3. Please indicate your religion:


4. Please indicate any temporary or permanent physical challenges you may have:


5. Please indicate your relationship status:


6. Please indicate your national origin:
7. Please indicate the combined annual income level for your entire household:

8. Please indicate your sexual orientation:

9. Please indicate the number of family members in your household, including yourself:

10. Please indicate your level of education:

Please indicate how you found out about the Feminist Women’s Health Center:
Other: Please Specify: _________________ FEMINIST WOMEN’S HEALTH CENTER
Please complete all information up to solid line

Today’s Date: ___/___/___ Name: ___________________________________ DOB: ___/___/___ Age: _____

Allergies: _________________________________ Pharmacy Name/ Number: _____________________________
*Lab results: You will only be notified if your results are abnormal. Results are reported in 5 – 7 business days. Please provide the address
where results can be mailed: _________________________ If you prefer to be called, provide your phone number here: _______________.
Purpose of Visit: (Please circle ALL that apply:)

1. Vaginal infection or pelvic pain
2. Screening for STI's 3. Bladder infection 4. Breast check

5. Pap Smear 6. Post-abortion care/concerns
7. Birth Control
8. Other:________________________
The following information will help us make decisions about your care today:
First day of last normal period: ____________________ Last date of sexual intercourse: ____________________
Current method/s of birth control (including condoms): ____________________
How long have you used your current method of birth control? ____________________
Please list any problems you are having with your birth control method: __________________________________
Do you use birth control every time you have intercourse? Circle one:
Current method/s of protection against sexually transmitted infections: ____________________________________ Do you use protection every time you have intercourse? Circle one: If applicable: number of sexual partners: ______________ Partners are: Male Do any of your partners have a sexually transmitted Length of time with current partner: __________months/years Have there been any changes in your medical history since your last visit? Explain:__________________________________________________________________________________________ List any current medications (over-the-counter or prescription) or herbs: _______________________________________
OFFICE USE ONLY

Lab: as applicable: Temp:_____ Resp:_____ B/P:____/____ Pulse:_____
Other:____________________________________________________ Pregnancy slide test: POS(+)/ NEG(-) HSV I: Client would like to receive positive test results? Yes  No 
Comments:____________________________________________________ Initials:_______________

EXAMINATION:
(Other/Deferred)
Description/Diagram
Pap: Yes/No
Cultures: Yes/No
GC/ Chlamydia/ Herpes/ Other:______________________________ Wet Prep: Yes/No
Yeast; Clue; Whiff; Trich; WBC’s: #__/hpf Assessment:
RNC/CNM/MD: __________________________ FEMINIST __________ Date:________________ Time:______ FEMINIST WOMEN'S HEALTH CENTER
MEDICAL HISTORY

Legal Name ______________________________________________ Preferred Pronoun (he/she/ze) ___________
Preferred Name______________________________________ DOB _____/____/_____ Age ________
Address ___________________________________________ Apt # ________ Phone (h) (____)_____-________
City _________________________ Within City Limits: Yes ( ) No ( ) County _______________________ State __________ Zip _________ (c) (____)_____-________ At what phone # may we contact you?_______________________ May we leave a message: Yes ( ) No ( ) Emergency contact: Name _______________________________________________________________________ Address ____________________________________________ Apt # ________ Phone (h) (____)____-_________ City _____________________________ State __________ Zip _________ (w) (____)____-_________ Years of Education: _____________Language you speak: English, Spanish, French, Other____________________ Can you read/understand English to fill out this form: Yes ( ) No ( ) If not English speaking, Interpreter’s name __________________________________________________________ Pharmacy # _______________________________________________ Religion ____________________________ DRUG ALLERGIES: __________________________________ FOOD ALLERGIES: ______________________ CURRENT MEDICATIONS: ____________________________________________________________________ Please circle Y for yes or N for no, or fill in the space for the following questions:
Contraceptive History (Birth Control):
Comments - Staff Only
1. Y N Do you need/want birth control method/information. If you answered NO, skip to # 7. 2. Y N Is this a non-abortion visit and you are having intercourse/ risk for pregnancy Current method of birth control used: __________________________________ How long using this method; ____________ Problems: Y N Describe: _______________________________________________________ What method do you want to use now? ______________________________
Methods used in past: (circle): Pills / Patch / Ring / Shot / Norplant / IUD / condoms / cervical cap / diaphragm / foam / gel / sponge / abstinence / withdrawal / sterilization / tubes tied / vasectomy / rhythm / Natural Family Planning / Emergency Contraception / other _______________ Sexual History/ Information: this information helps us with your care:
Age of first sexual experience ____Currently in sexual relationship: Y N # partners in last year: _____Do you practice safe sex Partners History (circle all that apply):
Has other partners, has same sex partners Social History:
Circle Y for yes or N for no to the following indicating your recent experience: 11. Y N Problems in living arrangements/schools 14. Y N Has anyone forced you to have sex 15. Y N Are you afraid of your partner/family member 16. Y N Do alcohol/drugs cause problems in your life? 17. Y N Have you ever abused alcohol? Yes ( ) No ( ) Drugs? Yes ( ) No ( ) 18. Y N Emotional/mental illness? Anti-Depressive, anxiety or psychotic medications? 19. Y N Do you feel you are in an abusive relationship? 20. Y N As a child did anyone touch your private body parts or ask you to touch theirs? 21. Y N Would you like referrals for any of the experiences above or do you need a counselor? 22. Y N Do you smoke? How many cigarettes/day ___________ 23. Y N Do you drink? How much alcohol do you drink per week __________________ 24. Y N Do you use recreational drugs? What kind? __________________________________ Date of last use__________________ Comments - Staff Only
25. Who helps and supports you with your problems ________________________ 26. Who do you live with __________________ OB History:
Complete below:
27. Total No. Pregnancies including current: _______ Living children: _______ Live births: ______ Miscarriages: ______ Abortions: _______ Ectopic/tubal: ____ Other: _____________________________ # of C-sections: ________ Last pregnancy when: __________ Problems with pregnancies: (high blood pressure, seizures, toxemia, gestational diabetes, birth defects) other: __________________ 28. Are you Rh neg: Y N Have you received Rhogam: Y N
29. Y N Trouble getting pregnant/staying pregnant
30. Y N Used fertility treatments/medications
31. Y N Had artificial insemination (s)
Personal Medical History:
Circle Y for yes or N for no to the following and circle items that apply: (Current & Past)
32. Y N Eye/vision problems, glasses/contacts 33. Y N Deaf/Mute. Do you know sign language Yes ( ) No ( ) 34. Y N Heart problems/palpitations/murmurs/surgery/MVP (Mitral Valve Prolapse) 35. Y N High Blood Pressure 36. Y N Strokes/Blood Clots in head, heart, brain/Head injury 37. Y N Varicose veins 38. Y N High cholesterol/ blood fats 39. Y N Diabetes/High Sugar: (insulin/diet /oral/) Only with pregnancy 40. Y N Bladder/Kidney problems/infections 41. Y N Headaches/migraine, stress related or other 42. Y N Seizures/epilepsy: Date of last seizure_____________ 43. Y N Thyroid conditions/ medications 44. Y N Liver disease/Hepatitis 45. Y N Stomach problems/gastritis/ ulcers/reflux disease 46. Y N Bowel problems/Colitis/Irritable bowel/Crohns 47. Y N Lung Problems/Disease/Asthma=(circle one) Childhood, Seasonal; Chronic 48. Y N Anemia/Low Iron/Sickle Cell/Thalassemias/Blood diseases/Lupus 49. Y N Gallbladder disease/Surgery 50. Y N Cancer 51. Y N Numbness in legs or arms 52. Y N Are you currently under care for a problem/illness by a health care professional? Explain ___________________________________________ 53. Y N Have you ever been hospitalized (except childbirth): Explain ______________________________________________________ _____________________________________________________________ 54. Y N Received blood products before 1978 55. Y N Do you faint with needles/finger sticks/pap smears 56. Y N Ever react to ANY DRUG/MEDICATION/FOOD: including (circle): barbiturates, anesthesia, shellfish, eggs, soy, Iodine, metals, latex ____________ 57. Y N Have you ever been put to sleep for any surgery? Did you have any problems-Y N 58. Y N Immunizations up to date: Last tetanus: ________ Rubella vaccination: Y N Hepatitis B: Y N HPV Vaccine: Y N 59. Y N Do you have any piercings in your mouth? 60. Y N Do you use herbs/vitamins/complimentary therapies Comments - Staff Only

GYN History:
Circle Y for yes or N for no to the following:
61. Y N Have you ever had a pelvic exam/ Pap smear? Date of last exam _____________
62. Y N Breast disease or surgery
63. Y N Breast/nipple discharge/leaking
64. Y N Are you breast feeding/nursing
65. Y N Mammogram
66. Y N Vaginal infections/itching /burning
67. Y N Vaginal pain/bumps/swelling/sores
68. Y N Sexually transmitted infections (circle all that apply):
Herpes, HPV, Chlamydia, Gonorrhea, Trichomonas, Syphilis, HIV, Hepatitis B, Group B Streptococcal Infection 69. Y N Pelvic inflammatory disease (PID) Date______ Treatment: ____________________________ 70. Y N Endometriosis/Uterine fibroids 71. Y N Cysts on ovaries 72. Y N Abnormal Pap (date) ___________ Treatment: Repeat pap (date) _____________ Colpo/Cryo/LEEP/Laser 73. Y N Genital circumcision 74. Y N Bleeding and/or pain with sex 75. Y N Did your mother take medications to prevent miscarriage Menstrual History:
76.
Are your cycles/periods regular? Yes ( ) No ( ) Sometimes ( ) # days in each cycle: ________ # days you bleed: _______ Use pads / tampons / other _______ # used on heaviest day(s) _______ 77. Y N Cramps/pain/bloating/depression 78. Y N Do you use medications/herbs/other __________________ for relief 79. Y N Bleed between periods 80. Y N Menopausal/Peri menopausal 81. First day of last period _____/______/_____ Normal ( ) Abnormal ( ) Family History:
Adopted: Y N
Fill in below: mom, dad, siblings, grandparents, aunts, and uncles 82. Y N Diabetes ________________________________________________ 83. Y N Heart attack before age 50 __________________________________ 84. Y N High Blood Pressure _______________________________________ 85. Y N Cancer (breast, ovarian, uterus) ______________________________ 86. Y N Osteoporosis _____________________________________________ 87. Y N High cholesterol __________________________________________ 88. Y N Alcoholism/addictions/mental illness _________________________ 89. Y N Problems with General Anesthesia____________________________ 90. Y N Birth defects/genetic illness _________________________________  What else would you like us to know about you? ___________________________________________________________________  I affirm that all of the medical information stated above is true and that I have not had anything to eat, drink or gum since__________ Client signature ____________________________________________ Date: _________________ Updated: ______________________ Counselor signature__________________________________________ Date: _________________ Updated: ______________________ RN Pre-op Signature_________________________________________ Date: __________________ Updated: _____________________ MD/NP Review ________________________________ Date:___________ Time:_________ Updated: _____________ Time: __________ APN/CRNA Review__________________________ Date:___________Time:_________ Updated: _____________ Time: ___________ This information is confidential and will not be released without your written permission.

Source: http://www.feministcenter.org/assets/pdfs/Wellness-Client-Forms.pdf

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