Kyle Parkway OB/GYN Associates
PATIENT INFORMATION
First Name:____________________________M.I:____ Last Name:______________________________
Address:________________________________City:_________________State:____Zip Code:________
Phones: (H)______________________(C)_______________________(W)________________________
DOB:_______________________Sex: M
F Marital Status:_________________________________
Ethnicity:__________________Race:____________________Language:__________________________
Emergency Contact Name:__________________Relation to patient:_________Phone:_______________
Preferred Pharmacy:______________________City:_______________Phone:______________________
RESPONSIBLE PARTY If the same as above: put “same”
First Name:____________________________M.I:____ Last Name:______________________________
Address:________________________________City:_________________State:____Zip Code:________
Phones: (H)______________________(C)_______________________(W)________________________
DOB:_______________________Sex: M
F Marital Status:_________________________________
Relation to patient:______________________Email Address:___________________________________
PRIMARY INSURANCE INFORMATION
Insurance:____________________________Policy Holder Name:_______________________________
Policy Holder Ph#_____________________DOB:__________Relation to Patient:___________________
SECONDARY INSURANCE INFORMATION
Insurance:____________________________Policy Holder Name:_______________________________
Policy Holder Ph#_____________________DOB:__________Relation to Patient:___________________
APPOINTMENT REMAINDERS
Preferred Time:______________Pref. Phone:_______________Okay to leave voicemail?:_____
REFERRAL SOURCE (Please circle one)
Newspaper
Television
Billboard
Direct mail/Magazine
Do you have an advance directive/living will?
Radio
Website/Internet
Friend/Family
Yes
Other
No
Medical Information: I authorize the physicians of this office to release any information they have acquired in the
course of my or my child’s treatment to my insurance company or companies or any third party payor so that they
may obtain payment for medical services rendered.
Insurance Authorization: I hereby authorize the physicians or staff to this office to furnish information to my
insurance carriers concerning myself or my child’s illness and treatments.
Assignment of Benefits: I authorize the insurance company or any third party payor to pay any benefits due directly
to this office should they accept assignment on my claim. I ALSO AGREE THAT I AM FINANCIALLY
RESPONSIBLE FOR THE ACCOUNT EVEN THOUGH INSURANCE MAY BE PENDING ON ALL OR
A ORTION OF THE CHARGES.
Sign:________________________________________________________Date:_____________________________
Kyle Parkway OB/GYN Associates
OBSTETRICS AND GYENCOLOGY
NEW GYN PATIENT INFORMATION
Medical History:
Date:___________________My appointment is with:__________________________________________
Patient name:________________________________DOB:_________________AGE:_______________
Reason for your visit today:______________________________________________________________
If pregnant, please provide Father of the baby’s name and phone#:_______________________________
If pregnant, please provide your pre-pregnancy WEIGHT:___________________HEIGHT:___________
Drug Allergies/Reactions:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Medication List: (Please provide a list of current medications, diagnosis, and the prescribing doctor)
Medication/Dose
Diagnosis (reason for med)
Prescribing Doctor
Do you take Calcium? Yes / No
If so, what is the daily dose?_____________________________
Current Birth Control:_____________________Do you have regular monthly periods?
Yes / No
Age at first period:____________________First day of last period:_______________________________
Periods are:
Mild
Moderate
Heavy
Cramps are: Mild
Moderate
Heavy
Kyle Parkway OB/GYN Associates
OBSTETRICS AND GYENCOLOGY
Are you experiencing any vaginal or urinary issues? (Circle all that apply)
Discharge
Odor
Burning
Itching
Frequency
Urgency
Loss of urine
Other:_____________________
Age at first intercourse:______ Sexually active? Yes / No
Number of partners (lifetime):________
Sexual preference: (please circle)
Homosexual
Heterosexual
Bisexual
Have you had a new sexual partner since last exam? Yes/No Do you desire testing for STDs? Yes / No
Are you having any libido changes? Yes / No (please explain):__________________________________
Do you have pain with intercourse? Yes / No (please explain):__________________________________
Infection History:
Live with someone with TB or exposed to TB? Y/N
Have you ever had a Positive TB test?
Y/N
If so, When?
History of STDs (circle all that apply):
Gonorrhea, Chlamydia, HIV, Syphilis, Genital
Warts, PID, Trichomonas, HPV
Does the patient or partner has history of Genital Hepatitis B, C ?
Herpes?
Y/N
If pregnant, have you had a rash or viral illness since Comments:
last menstrual period?
Y/N
History of Varicella virus (Chickenpox)?____________________________________________________
Immunizations: Please indicate if you have received the vaccine (Yes/No) and date if applicable:
Varicella Virus (chickenpox):_________Last TDAP:____________Last Influenza (flu):__________
Please indicate if any of the below have been used since being pregnant or since your last menstrual
period.
Do you use tobacco products?
Yes/No
About______cigarettes per day
Do you Dip? Yes/No
Former Smoker?
Yes/No
Quit date:_____________________________________
Do you drink alcohol?
Yes/No
About__________drinks per week
Recreational Drug Use?
Yes/No
If yes, please list:_______________________________
History of Drug abuse?
Yes/No
If yes, please explain:____________________________
_____________________________________________________________________________________
History of domestic violence/abuse?
Yes/No (please explain)
_____________________________________________________________________________________
_____________________________________________________________________________________
Kyle Parkway OB/GYN Associates
OBSTETRICS AND GYENCOLOGY
Have you ever had a Pap smear? Yes/No
Last Pap smear date:_____________Results:_____________
Have you ever had an abnormal pap smear?
Yes/No
If yes, please give year and any procedures:__________________________________________________
Last Mammogram:______________________Results:_________________________________________
Have ever had an abnormal mammogram? Yes/No
If yes, please give year and any procedures:__________________________________________________
Do you do monthly breast exams? Yes / No / Occasionally
Do you diet?
Yes / No
Do you exercise?
What type?_________________________________________________
Yes / No
How often & how long?________________________________
Please list all pregnancies (including abortions, deliveries, ectopic, miscarriages, and still-births)
Date: GA
Month in
/year
wks
(40=
full
term)
Length
of
Labor
Birth
Weight
Sex:
Male
or
Female
Type
of Epidural?
delivery
Yes/No
Vaginal or
C-Section
Place of Complications
Delivery
Comments:___________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Kyle Parkway OB/GYN Associates
OBSTETRICS AND GYENCOLOGY
Medical Ploblems:
Date of Diagnosis
Medical Problems/Treatment
Please List All Surgeries/Hospitalizations:
Date
Surgery/Reason for Hospitalization
Review of Systems:
Please indicate if you are having any current problems in the following areas by marking an “X” in the
appropriate column.
General Wellness
Yes__ No__
Muscle/joints/bones
Yes__ No__
Eyes
Yes__ No__
Skin
Yes__ No__
Ear/Nose/Throat
Yes__ No__
Neurological
Yes__ No__
Heart/Circulation
Yes__ No__
Psychiatric
Yes__ No__
Lungs/Breathing
Yes__ No__
Endocrine
Yes__ No__
Stomach/Digestion
Yes__ No__
Blood/Lymph
Yes__ No__
Allergies
Yes__ No__
Reproduction/Urinary Yes__ No__
Kyle Parkway OB/GYN Associates
OBSTETRICS AND GYENCOLOGY
Disease
Mother
Father
Maternal
Maternal
Paternal
Paternal
Grandmother Grandfather Grandmother Grandfather
Brother
Sister
Other: Aunt,
Uncle, etc.
Alcoholism
Anemia
Arthritis
Asthma/lung
problems
Blood Clots
Bloody
Stools/Colon
Cancer
Diabetes
Heart
Disease
High Blood
Pressure
High
Cholesterol
Kidney
disease/UTIs
Liver Disease
Loss of Urine
Mental
Illness
Osteoporosis
Seizures
Stomach
Ulcers
Stroke
Thyroid
Disease
Tuberculosis
Other
Completed by:_____________________________Signature:_______________________Date:________
Family History Questionnaire for Common
Hereditary Cancer Syndromes
Patient Name: ______________________________________ Date of Birth: ___________________ Age: _______________
Height: ___________ Weight: ___________ Age of First Period: __________ Age at first child (if applicable):________
Are You Menopausal: Yes or No Have you ever used Hormone Replacement Therapy? Yes or No
Has anyone in your family had genetic testing for a hereditary cancer syndrome (Ex: BRCA or Lynch)? Yes or No
Please mark below if there is a personal or family history of any of the following cancers and indicate family relationship and
AGE at diagnosis in the appropriate column. Consider parents, children, brothers, sisters, grandparents, aunts, uncles, and cousins.
BREAST AND OVARIAN CANCER (BRCA)
You (age
diagnosis)
Y
N
Breast cancer
Y
N
Y
N
Breast cancer in both breasts
OR multiple primary breast
cancers
Ovarian cancer
Y
N
Male breast cancer
Y
N
Are you of Jewish descent?
at
Siblings / Children
(Who + age at
diagnosis)
Ex: Brother 36
yrs
Mother’s Side
(Who + age at
diagnosis)
Ex: Aunt 44 yrs
Father’s Side
(Who + age at
diagnosis)
Ex: Uncle 65
yrs
COLON AND UTERINE CANCER (Colaris)
Y
N
Uterine (endometrial) cancer
Y
N
Colon cancer
Y
N
Y
N
Ovarian,
stomach,
kidney/urinary tract, brain OR
small bowel cancer
10 or more colon polyps found
in a lifetime
OTHER CANCERS
Y
N
Prostate Cancer
Y
N
Y
N
Pancreatic
(Col/BRCA)
Melanoma
(BRCA)
Cancer
(BRCA)
Patient’s Signature:__________________________________________________ Date: _______________
For Office Use Only:
BRCA/Lynch Testing Indicated?:
Patient offered hereditary cancer testing?
Follow-up appointment scheduled:
YES
YES
YES
NO
NO
NO
If YES:
ACCEPTED
DECLINED
Date of Appointment:______________________
MD Signature: _____________________________________________________
BRCA – Personal or Fam. History
One person with (out to 2nd degree)

Breast Cancer at 45 or younger

Ovarian Cancer at any age

Male breast cancer any age

Breast Cancer + Jewish Heritage

Bilateral Breast at 50 or younger

Triple Neg Br.Ca. at 60 or younger
Date:________________
Lynch Syndrome (Colon/Endometrial Cancers)
Two persons with (out to 3rd Degree)

2 Breast Cancers at 50 or younger

Breast & Ovarian (any age)
Three Persons with (out to 3rd degree)

Breast and/or Ovarian and/or
Pancreatic (any age)
Personally affected with:

Colon or Endometrial at ≤ 50 or younger
Family History of Colon, Endometrial, + another Lynch
Cancer
(gastric, ovarian, brain, kidney, small bowel)

2 or more Lynch cancers, 1 dx ≤ 50
Kyle Parkway OB/GYN Associates
Request for Confidential Communications
The HIPAA Privacy Rule gives individuals the right to request a restriction on uses and disclosures of
their protected health information (PHI).
I certify that I understand the privacy risks of mail, telephone and email. I hereby authorize a
representative or my physician to mail, call, or email me with communications regarding my healthcare,
including but not limited to such things as appointment reminders, laboratory results and referral
arrangements. I understand that I have the right to rescind this authorization at any time by notifying us
in writing.
Name of Patient: ________________________Effective Date: ___________________ DOB: _______
If we need to reach you during business hours regarding test results, how may we reach you?
(check all that apply):
 Home Phone: _________________________ Work Phone:_________________________________
 Leave a message with detailed information
Leave a message with detailed information
 Leave a message with call back number only
Leave a message with call back number only
 If emergency, contact me at this number
 If emergency, contact me at this number
 Cell Phone: ___________________________
 Written Communication:
 Leave a message with detailed information
 Mail to home address
 Leave a message with call back number only
 Mail to alternate address (see below)
 If emergency, contact me at this number
Alternate Address: ____________________________________________________________________
City/Town, State: ____________________________________ Zip Code: _______________________
I give permission to send test results via secure encrypted email: Yes ____ No ____
E-mail address _______________________________________________________________________
I give permission to disclose and discuss any information related to my medical condition(s) to/with
the following:
___________________________________ Relationship _____________________________________
___________________________________ Relationship _____________________________________
___________________________________ Relationship ______________________________________
Patient Signature _________________________________________________ Date ________
Parent/Legal Guardian _____________________________________________ Date _________
Kyle Parkway OB/GYN Associates
Consent to Treat and Health Care Agreement
1. Consent to Treat
I hereby consent to evaluation, diagnostic procedures, testing, and treatment as directed my physician or
his/her designee. I understand that Kyle Parkway OB/GYN Associates includes teaching facilities and
therefore I may be attended to by students and residents of various disciplines and affiliated with various
educational programs. I understand that I may request and receive information on the specific
affiliation(s) of any particular healthcare provider I encounter during my care.
I understand that this Consent to Treat will be valid for each visit I make to the Kyle Parkway OB/GYN
Associates until revoked by me in writing.
2.
Consent to Release Information
I acknowledge that Kyle Parkway OB/GYN Associates may release my protected health information as
necessary for treatment, payment and health care operations and acknowledge that Seton’s Notice of
Privacy Practice provides information on how my protected health information may be used and/or
disclosed for these purposes. I understand that protected health information pertains to my diagnosis
and/or treatment, and includes, but is not limited to, information related to my health history, diagnosis,
treatment, prognosis, mental illness (excluding psychotherapy notes), use of alcohol or drugs,
prescriptions and laboratory test results, including HIV or the diagnosis of AIDS.
I understand that use or disclosure of my protected health information may be necessary before my
insurer will pay for the cost of my medical treatment and that if I refuse to consent to this disclosure I
may be required to pay the entire cost of medical care provided by Kyle Parkway OB/GYN Associates
I acknowledge and consent to allow Kyle Parkway OB/GYN Associates to use health information
exchange systems to electronically transmit, receive and/or access my medical information, which may
include, but is not limited to, treatments, prescriptions, labs, medical and prescription history and other
protected health information. I may “opt out” and not have my protected health information disclosed
through health information exchange systems by providing the signed Seton “opt-out” form to the
practice location where I receive treatment.
3. Assignment of Insurance Benefits/Patient Financial Responsibility
I assign and transfer to Kyle Parkway OB/GYN Associates all rights, title and interest in payments from
third-party payors, including but not limited to, health plans, health insurers, Personal Injury Protection
(PIP)/Uninsured Motorist/Under Insured Motorist (UIM/UM), auto or homeowner’s insurance. I
understand that it is my responsibility to know my insurance benefits and whether or not the services I
receive are a covered benefit. I understand and agree that I will be responsible for any deductible, co-pay
or balance due that Kyle Parkway OB/GYN Associates are unable to collect from my third-party payor
for whatever reason. If my account becomes delinquent and it is necessary for the account to be referred
to attorneys’ or collection agencies, or lawsuit filed, I agree to pay all patient charges, reasonable
attorney’s fees and collection expenses.
4. Medicare/Medicaid/Insurance Benefits
If I am eligible for health care benefits under any federal or state program, including, but not limited to
Medicare or Medicaid, I certify that the information given by me in applying for payment under any such
programs is correct. I authorize any holder of medical or other information about me to release to the
Social Security Administration or Contractors any information needed for any federal or state program
related claims. I request that payment or authorized benefits be made to Kyle Parkway OB/GYN
Associates on my behalf. I understand that I am financially responsible for any deductible, co-pay or
balance due under these programs.
5. Lab/X-ray/Diagnostic Services
I understand that I may receive a separate bill if my medical care includes lab, x-ray, or diagnostic
services that are not provided by Kyle Parkway OB/GYN Associates or its employees. I also understand
that I am financially responsible for any deductible, co-pay or balance due for these services if they are
not reimbursed by my third-party payer for whatever reason.
6. Consent to Photograph/Digital Imaging
I consent to photographs/digital images for treatment, and to verify identity for payment purposes. I
understand that the Seton Healthcare Family will retain the ownership rights to these photographs/digital
images, but that I will be allowed access to view them or obtain copies.
7. Accidental Exposure of Health Care Worker
I understand that Texas Law provides and I give consent that in the event a healthcare worker is exposed
to my blood or body fluids, my blood may be tested for the HIV antibody and other communicable
diseases at no cost to me.
8. Notice of Privacy Practice
I acknowledge receipt of the “Notice of Privacy Practices” from Kyle Parkway OB/GYN Associates.
____________________________________
Patient Printed Name
___________________
Patient Date of Birth
____________________________________
Patient/Responsible Party Signature
___________________
Date
____________________________________
Witness
___________________
Date