NEW PATIENT
INFORMATION
PACKET
WELCOME TO OUR PRACTICE!
The team at University of Louisville OB/GYN & Women’s Health is dedicated to providing you
with the best care available.
Our multidisciplinary teams include high-risk maternal-fetal medicine physicians, infertility
doctors, cancer specialists and urinary and pelvic floor experts, as well as other medical
specialists.
University of Louisville Physicians OB/GYN & Women’s Health hours of operation are Monday
through Thursday from 8:00 a.m. until 4:30 p.m. On Fridays, we are open from 8:00 a.m. until
12:00 p.m.
Parking is available on Chestnut or any surrounding street except for Jackson Street or in the
UofL Out-Patient Center located at directly across the Out-Patient Center at 401 East Chestnut
Street, Louisville, Kentucky or at the UofL Hospital Garage at 530 South Jackson Street,
Louisville, Kentucky. The garage at both Chestnut Street and the Hospital garage charge $1.00
per hour up to a maximum of $9.00 per day. Our practice does not validate parking for any
garage.
For your convenience, we provide the following: baby changing areas, vending machines, and
an in-house lab where we can provide you vaccinations such as flu, hepatitis A, hepatitis B,
tetanus, diphtheria, pertussis, pneumonia, and TB skin testing.
For your first visit to our office, please arrive at least 15 minutes prior to your scheduled
appointment time. Please bring with you a current picture ID, a list of all medications you are
currently taking along with the following completed forms which are included in this packet:



Patient registration
Medical History
Consent to medical care
Completing all paperwork prior to your arrival enables us to being your care quickly and better
serve your medical needs. If you have insurance coverage, you will need to present your
insurance card(s) at the time of your appointment. Co-pays and deductibles are also due at this
time. If your insurance company requires pre-authorization or a referral from your primary
care physician, please obtain this prior to your appointment.
If you have any questions or concerns prior to your visit, please do not hesitate to call us (502)
561-8850. We look forward to meeting you.
Review of Clinic Policies
Registration

Plan to arrive 15 minutes prior to your scheduled appointment time. If you are more
than 30 minutes late, you will be considered a “no-show” and will be rescheduled. After
three missed appointments without calling to reschedule, you will be discharged from
our practice. Cancellation notification must be made 24 hours prior to your
appointment. You may reschedule or make an appointment by calling our office
502-561-8850.

All copays are due at the time of service at registration. If you are unable to pay your
copay at the time of your appointment, you will be asked to reschedule.

A financial counselor may be available to speak with you during normal hours of
operation if you should need assistance with copayments for office visits or surgical
procedures. You may contact the financial counselor in during normal hours of
operation at 561-6863.

All patients are required to fill out the federally mandated KASPER form to track
prescription narcotics
Seeing the Physician/Resident

The length of each appointment will depend on the nature of your visit. Because we are
a teaching facility, you may be seen by a resident/attending physician.

Bring with you any medical records, labs, or test results regarding your condition done
at another facility, list of medications, and a list of drug allergies.

Due to limited exam room space and privacy for other patients, please limit one person
in the exam room with you. If you have children who need supervision during your
exam, please bring someone to stay with them and supervise them while waiting in the
lobby. Our staff will not be held responsible for supervision of your children during your
exam.
Prescription Requests

You may contact our office at 502-561-8850 for medication refills. Refills will be
addressed within 24-48 hours during normal business hours. If you call when our clinic
is closed, your refill will be addressed within 24-48 hours after our offices are open.
After Hour Emergencies
If you have an emergency after hours that cannot wait until normal business hours, please call
911. If you need to reach one of our physicians, please call 502-561-8850 to reach our afterhours answering service who will contact the physician on-call. Please do not call the
answering service for refills on medications.
Review of Clinic Policies
Contacting the Clinic

For appointments, medical questions, medical records, work notes, school, notes,
attorney requests, and disability forms, please call 502-561-8850. Your call will be
directed to the appropriate staff member.
Radiology/Laboratory/Testing

If you are sent to UofL Hospital to either the emergency room or for labs that cannot be
performed in our office, UofL Hospital will send you a separate bill for services which
may include but are not limited to, hospital fees, physician fees, lab fees, radiology fees,
etc. You may contact UofL Hospital at 502-562-3000 and request to speak to a financial
counselor prior to any testing. UofL Hospital is an independent service from University
of Louisville Physicians OB/GYN & Women’s Health and will bill separately from our
clinic.
You have an appointment with Dr.
PLEASE PRINT ENTIRE FORM:
Patient Name:
_______
Address:
___________ _/
City:
Phone #:
Time:
Referred By:
__
State:
Work #:
Cell #:
_____
Spouse/Parent:
/
Address:
/
City:
____
Phone #:
____
Cell #:
______
Date:
Zip:
Soc. Sec. #:
Birth Date:
Employer:
_
/
_______
Email:
_/
Occupation:
_
Soc. Sec. #:
_
State:
________ /
Zip:
Work #:
Email:
Name of nearest relative not living with you:
Relationship:
__
Address:
_
City:
State:
Zip:
__
_____
Birth Date:
/
______ /
Occupation:
Employer:
Address:
Phone #:
Work #:
Cell #:
__
____
AUTHORIZATION TO RELEASE INFORMATION: I HEREBY AUTHORIZE University of
Louisville Physicians OB/GYN & Women’s Health to release any medical or incidental information that
may be necessary for either medical care or in processing applications for financial benefit.
ASSIGNMENT OF INSURANCE BENEFITS: I HEREBY AUTHORIZE direct payment of
surgical/medical benefits to University of Louisville Physicians OB/GYN & Women’s Health for
services rendered by them in person or under their supervision. I understand that I am financially
responsible for any balance not covered by my insurance.
PATIENT NAME (Print):
___
PATIENT (GUARDIAN) SIGNATURE:
___
Date:
Date:
**A photocopy of these assignments shall be valid as the original.
Revised 11/2/12 be
ACB, 3rd Floor
550 South Jackson Street
Louisville, KY 40202
(502) 561-8850
Date of Visit: ______/______/______
Patient Label
Age:
Height:
BMI:
New Patient History
Please note: All information is confidential and will only be used for the purpose
of ensuring you the best treatment possible. Please answer all areas:
Why have you come to the office today?
Are you having any problems? Where? How long have you had the problem(s)?
Who referred you to our practice:
Who is your usual Ob/Gyn?
□Self □Friend □ Physician (List Name)
_____________
____________
Location:
P a s t M e d i cal H ist o r y (√ If you have or have ever had)
√
Anemia/blood disease
Arthritis
Asthma
Bladder problem/infections
Blood transfusion
Bowel disorder
Cancer
Diabetes
Endometriosis
Epilepsy/neurologic disease
Other medical problems (list):
√
Gall bladder disease
Headaches/migraine
Heart disease/valve problems
High blood pressure
Kidney disease
Leukemia
Liver disease/hepatitis
Lung disease
PCOS (Polycystic Ovarian Syndrome)
Prior Pulmonary Embolus (PE)
√
Prior blood clots (DVTs)
Reflux/Hiatal Hernia
Skin disease
Stomach ulcer
Thyroid disease
Tuberculosis
Varicose veins/phlebitis
Weight loss/gain ≥ 10 lbs
S u r g e r i e s / O p e r a t i o n s (Any procedure, including D&C’s)
Type/Reason
Date
Location
Current Medications
Other Illnesses/
Hospitalizations
Type/Reason
(Include any hormones,vitamins,herbs,over
over the counter & nonprescription meds)
Physician
Allergies/Reactions
(List any drug or food
Dose
allergy & reaction type)
Year
History
First day of last menstrual period:
/
/
Have you ever had an abnormal Pap test? Yes
Do you have regular monthly periods? Yes □ No □
Usual number of days from start of one period to start
of the next:
Any recent changes?
Describe:
Number of days of bleeding:
Yes
□
No
□
□
No
□
Have you ever had a procedure on your cervix due to an
abnormal pap test? (LEEP, Cryo/Cone)
Year:
When was your last Pap test?
Yes □
No
□
□ Normal □ Abnormal
Have you ever had a mammogram?
Yes □ No □
Year of last: _____ Result:
□ Normal □ Abnormal
What was the Pap result?
Age periods began:
Do you have problems with pelvic pain? Yes
When?
□
No
□
Present method of birth control:
□ Pills-Patch-Ring
□ Depo Provera □ IUD
□ Rhythm Method □ Male Condom
Are you sexually active?
Yes □ No □ □ Diaphragm
□ Implanon
□ NONE
Do you have pain with intercourse?
Yes □ No □ □ Withdrawal
□ Female Sterilization (Tubal Ligation)
Sexual partner(s) is/are: Men □ Women □ Both □
□ Male Sterilization (Vasectomy)
Have you ever had any of the following infections?
□ Gonorrhea □ Chlamydia □ Herpes
□ HPV
□ HIV
□ PID
□ NONE
Number of times: ________
Year(s): _________
Weight at age 20: ________ Current Weight: ________
Have you ever used Birth Control Pills?
Yes □ No
Age when started birth control:_______ Age when last
stopped:_________
□
Hirsutism (excessive hair growth) & Acne
Do you feel that you have problems with excessive hair growth?
If yes, circle all areas of concern:
Face
Chest/Breasts
Back
Yes
Stomach
□
No
□
Arms
Legs
Thighs
Age that hair growth became noticeably worse? ________ Does this continue to worsen?
Prior Treatments: □ Waxing □ Shaving □ Plucking
Treated how often? _______________________
Yes
□
No
□
□ Creams □ Laser □ Spironolactone(Aldactone)
Do you have problems with excessive acne?
Yes
□
No
□ At what age did acne problems begin?
Does this continue to worsen?
Yes
□
No
□
Current acne treatment:
Obstetrical History
Immunizations
Number
Type
Date
Date
Total number of pregnancies
Have you ever had Chicken Pox?
Yes/No
Term births (>37 wks)
Chicken pox vaccine
Flu vaccine
Premature (20-37 wks)
Hepatitis A vaccine
Pneumonia vaccine
Miscarriages (<20 wks)
Hepatitis B vaccine
Other:
Ectopic (tubal) pregnancies
Rubella/MMR vaccine
Elective abortions
HPV vaccine (Gardasil)
Living children
Tetanus-Diptheria-Pertussis
TB test
Obstetrical History: Please list all pregnancies in order
Outcome (Yes/No)
Month
/Year
1st
2nd
3rd
4th
5th
6th
7th
Live born
Miscarriage
Abortion
Ectopic
Delivery:
Vag/C-Section
Complications
Length of Time
to Conceive
Required Fertility
Treatment
Current
Partner?
Social History:
Currently Use:
Occupation:
Diet
Tobacco: Yes □ No
Status: Married / Single
Restrictions?
Have you ever smoked >100 cigarettes? Yes □
Drinks/week:
Alcohol: Yes □ No □
No. of
Meals/day:
Caffeine: Yes □ No □
(coffee, soda, tea)
Other drugs: Yes □ No □
Skip meals?
(Including marijuana)
Partner / No Partner
Length of time with current partner (years):
Routine exercise: Yes □
No
□
Hours per time: _____________
Times/week:
_____________
Type: _________________________________
Routine exposures to chemicals? Yes □
No
□
Packs/day:
Years:
No
□
Drinks/day:
Type(s):
□
Genetic Diseases:
Cystic Fibrosis
Cystic Fibrosis (CF) is a hereditary disease that affects mainly the lungs and digestive system, causing progressive
disability, recurrent infections and usually early death. CF does not affect intelligence or appearance. Average life
expectancy is around 37 years. Approximately 1 in 29 Caucasians carry this gene defect, as well as 1 in 46 Hispanics,
and 1 in 65 African Americans. If you are a carrier, you have a 50% chance of your child being a carrier, which would
not be affected. If your partner is also a carrier, you have a 25% chance of having a child with the disease. The
American College of Obstetricians and Gynecologists recommends offering all patients testing for CF. Current testing
can determine if you carry the gene(s) responsible for this disease. Current testing can detect the genes that are
responsible for >90% of cases of CF. Testing may not be covered by your insurance. The test costs approximately
$395 to perform if not covered by insurance. If you do not have insurance coverage for this, you may be able to
coordinate a reduced fee with our laboratory if you arrange this before having the test done.
Have you been tested for Cystic Fibrosis (CF)?
Would you like to be tested: Yes □
No
□
Yes □
No
□
Family History (Parents, Grandparents, Siblings, Aunts/Uncles)

Illness
Alcohol or drug addiction
Birth defects/Mental retardation
Bleeding disorders
Blood clots in lungs or legs
Breast cancer
Cancer-Colon
Cancer-Ovary
Cancer-Uterus
Diabetes
Endometriosis
Heart disease
Hepatitis
High blood pressure
High cholesterol
HIV
Infertility
Mental illness/depression
Osteoporosis (weak bones)
Sickle Cell/ Thalassemia
Stroke
Tuberculosis
Any other genetic diseases
Recurrent miscarriages?
List miscarriages for both
your family’s side and
your partner’s
Early menopause <40 years old.
(Premature Ovarian Failure)
Other:
What is your ancestry? □ African-American
□ American Indian
□ Ashkenazi Jewish
□Northern European
List affected relative(s)
and age at onset
Age of mother at
menopause if known:
□East Asian/Pacific Islands
□Caucasian
□ Eastern European
□Hispanic/Latin American
□South Asian
□Middle Eastern
Fertility History (May STOP here is not being seen for fertility reasons)
Note: In order to help us more efficiently treat you, please obtain copies of your past fertility treatments, operative
reports, IVF cycle, ultrasound reports, labs and hard copies (Films or on disk) of any Hysterosalpingogram
(HSG) (X-ray test of your tubes) that you have had done. It is important that we review the HSG films that were
previously done. Please bring these records to your appointment with you.
Yes □
□
How long have you been actively trying to conceive?
_____ yrs
_____ mo.
Do you use lubricants?
Type: _________
Number of times of intercourse per week? _____
Do you douche?
Yes □ No □
Frequency of intercourse near ovulation: _______
How long have you been off any birth control?
_____ yrs
_____ mo.
No
Do you have insurance coverage for fertility?
Yes □
No
□
Type of insurance benefit:
□Testing/diagnosis only □ Testing & treatment □Artificial insemination
□ IVF
Prior Fertility Evaluation/Labs/Treatment
Treating physician location:
Have you had an HSG
(x-ray study of tubes)?
Laparoscopy?
Dates: ________________
Number of times: _______
Ovulation Testing?
Pelvic Ultrasound?
Date: _________________
Was a cause of infertility found?
Yes □
No
□
When?
Result?
Where was this performed?
Yes □
No
□
When?
Findings?
Were they able to detect if your tubes were open?
Yes □
Yes □
No
No
□
□
Prior fertility treatments:
Clomiphene (Clomid)
Letrozole (Femara)
Intrauterine Insemination (IUI)
Ovulation Induction with injectable fertility medications
(Menopur, Bravelle, Repronex, Gonal-F, Follistim)
In Vitro Fertilization (IVF)
Frozen Embryo Transfer (FET)
(Menopur, Bravelle,
(Menopur, Bravelle, Repronex, Gonal-F, Follistim)
Yes □ No □
Do you consistently ovulate?
Checked by: Temperature/Urine Ovulation
Testing/Ultrasound/ Blood
Where done?
Any abnormal findings?

Please list dates, dosage, number of cycles:
Male Partner History
Partner’s Name:
Age:
Medical problems:
Take routine medications or supplements?
Past surgeries:
Has he had a semen analysis?
Yes □ No
When?
Height:
Medications or supplements:
Family History of diseases:
□
Results?
Has he seen a Urologist?
Urologist’s Name/Location?
Yes □
No
□
History of hernia or testicular surgery
Yes
□
No
□
History of injury to testicles
Yes
□
No
□
Exposure to chemicals/radiation/toxins?
Routine hot tub use:
Occupation?
Previously fathered a child?
Age of children:
Weight:
□
Yes □
No
□
□
□
No
□
Yes
No
Wears: Boxers/ Briefs
Yes □ No
□
Trouble with erections?
Trouble with ejaculation?
Yes
Does he currently smoke?
Amount: Packs/day:
Yes □ No
Years:
□
Currently or has ever used any type of steroids?
Yes □ No □
Length of time since last usage:
Use marijuana or other drugs? Yes □
Last use:
No
□
Any illnesses/fevers in the past 3 months?
Yes
□
No
□
Yes □
No
□
History of sexually transmitted diseases?
Yes
□
No
□
Alcohol use:
What is your ancestry? □ African-American
(circle)
□ American Indian
□ Ashkenazi Jewish
□Northern European
□East Asian/Pacific Islands
□Caucasian
□ Eastern European
□Hispanic/Latin Am.
□South Asian
□Middle Eastern
CONSENT FOR MEDICAL CARE
I wish to have treatment given to:  me  my child  my ward by University of Louisville Physicians
OB/GYN & Women’s Health. I voluntarily consent to routine diagnostic and therapeutic procedures such as
physical exams, vaccinations, and lab tests. As part of the care to be given, a test may be performed for human
immunodeficiency virus infection (HIV/AIDS), hepatitis, or other blood-borne infectious or communicable
diseases. If the doctor orders the test for diagnostic purposes, because of my/the patient’s medical history,
symptoms, or conditions.
I hereby acknowledge that I have read and fully understand the information set forth above and that any questions
have been answered to my satisfaction.
____________________________________________
Patient
________________________________
Date
I hereby state that I am the  parent  legal representative of the patient and am authorized to sign on their
behalf.
____________________________________________
Parent/Legal Representative
________________________________
Date
I have reviewed the above information with the patient, parent, or legal representative as appropriate.
____________________________________________
Parent/Legal Representative
________________________________
Date