Chart#----- Date: ------Iriit: ------Name: ______FIRS T MIDDLE lAST SUFFIX NICK NAM E DATE OF BIRTH

D Same as Patient (if same as Patient, do not complete) Name: ______

STREET FIRST , MIDDLE , LAST Social Sec.#------····---··----··-·-­ CITY, STATE, ZIP CO DE Address: ._ STREET Primary Care Physician: ------~----

CITY, STATE, ZIP CODE

Social Sec.#·------D Single D Married D Divorced

D Separated D Widowed STREET

OTY, ST ATE , ZIP CODE D Not Hispanic or Latino Name: D African /IJT'eican or Black D Native Hawafian/Other Pacific D /IJT'eican Indian or Alaska Native D Other Race Relationship: ------D Pacific Islander D White or Caucasian Phone:

Company: ______Address: ·---·------Insured's Employer: ______Address: ------Insured's Name: Patient Relationship: D Self D Spouse D Child D Other DOB: ______Gender: D Male D Female Phone: ______

Policy Group ID: ------· ______Individual ID: ------· Copay: Company: ______Address: ______

lnsured's Employer. Address: -----·

lnsured's.Name: Patient Rela~ionship: D Self D Spouse D Child D Other DOB: Gender: D Male D Female Phone: Policy Group ID: ______Individual ID: ______Copay:

Mail Order Pharmacy: ______

How did you hear about COG? D Family/Friend D Internet D COGWebsite D Facebook D PrintAd D Insurer Info D Hospital Referral D Other. ASSIGNMENT OF BENEFITS AND FINANOAL RESPONSIBILITY: I authorize and assign direct payment of insurance benefits to Cheyenne OB/GYN for my care for all amounts due from my primary and/or supplemental insurance carrier{s). I understand and agree that I am financia lly responsible for payment of any charges which insurance does not pay. I furtherunderstand, lacking timely payment by my insurance, I will be responsible for payment of my account I understand that services are provided to me, the patient and not my insurance company. I understand and agree that I am totally responsible for payment of all Cheyenne OB/GYN charges and the fees of other professional providers for care rendered to me. By signing below, I consent to be contacted by mail, email, phone and or cell phone regarding my account by the creditor, its successors or assigns. This consent indudes any updated or additional contact information that I may provide and indudes contact that emplays auto-dialer and/or prerecorded messages. If my bill is not paid in full thirty (30) days from the date of service received, I agree to be responsi ble for all attorney fees and court costs in collecting any sums due and owing for services received. Signature of Patient or Responsible Party if Minor ______Date ------Patientlnfonn ntionSheet_ New_20 17.PDF Patient Privacy Practices

The privacy provisions of federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), apply to health information created and maintained by the practice. The Department of Health and Human Service~ . (HHS) has issued the regulation, "Standards for Privacy of Individually Identifiable Health Information", applicable to entities covered by HIPAA. The Office of Civil Rights (OCR) is the department component responsible for implementing and enforcing the privacy regulation. The privacy standards are designed to provide basic, federal protections for an individual's protected health information. Each state has existing privacy laws that may · still apply and to which the practice is already complying. Cheyenne Obstetrics and Gynecology (COG) is required by law to maintain the privacy of your health.information and to provide you with a description of our legal duties and privacy practices regarding your health information. The current notice is given to each patient at their initial consultation and an additional copy is available upon request.

I acknowledge that I have been informed of, inspected, and/or obtained a copy of the "Notice of Privacy Practices"

Patient Name Patient#

Patient or Guardian Signature Date

I authorize the following person(s} to receive or review correspondence regarding my private health information:

Name Relationship

Name Relationship

I authorize the results or appointment reminders to be left on my answering machine at:

t- Home: yes/no Cell: yes/no Work: yes/no

.J C{fy_enne OB GYN ...... _.._C)\ Generations of Excellence. ;;:,/ Caring for Women.

General Consent for Care and Treatment Consent

TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessmy to identify the appropriate treatment and/or procedure for any identified condition(s).

This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services. I

You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions.

I voluntarily request a physician, and/or mid level provider (Nurse Practitioner, Certified Nurse Midwife, or Clinical Nurse Specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s).

I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

Signature of Patient or Personal Representative Date:

Printed Name of Patient or Personal Representative Relationship to Patient

Printed Name of Witness Employee Job Title

Signature of Witness Date

REVISED: January 4, 2018 Page 1/3 Health History Form Date:

Name: DOB:

Reason for Visit Today:

Medical History: Do you have any health problems? (Check all that apply)

Anxiety Lung Problems Arthritis Migraine Headaches Asthma Neurologic Problems Bladder or Kidney Problems Polycystic Ovarian Syndrome Clots Seasonal Allergies History of Blood Transfusion Serious Injuries Breast Problems Thyroid Problems Depression Stomach Ulcers Stomach/Bowel Problems Other: ~~~~~~~~~~~~ Heart Problems Other: ~~~~~~~~~~~~ High Blood Pressure Other: ~~~~~~~~~~~~- High Cholesterol 0th er:

Please explain any checked boxes:

Past Surgical History Date of Surgery Type of Surgery Complications

Medications (List all current medications including over the counter meds.) Medication Dose

Allergies Medication Reaction

Continue to back of page ~ Page 2/3 Health History Form

Name: Family Medical History Has anyone in your family had these medical conditions? Who and what relation to you?

Diabetes High Blood Pressure Ovarian Cancer Stroke/Blood Clot Thyroid Problems Uterine Cancer §Heart Disease §Breast Cancer §Colon Cancer

Other:

Are there any genetic or inherited health problems in your family? If so, what was it and how were they related to you?

Gynecological History

Age at first period: Regular periods?

How many days from the start of the period to the start of the next period?

How long does your period last? Is it: D Light D Moderate D Heavy

Are your periods painful? D No Oves, explain:

When was the first day of your last menstrual period?

Are you certain of this date?

Are you sexually active? Oves 0No

What are you using for contraception?

Are you having symptoms of menopause? D No Oves, explain:

At what age did you stop having periods?

Are you using ? 0No Oves, explain: ------

Pap Smear History

When was your last pap? Was it normal?

Have you ever had an abnormal pap? 0No Oves, when?

What was wrong with it?

How was it treated? Continue to next page Page 3/3 Health History Form Date:

Name: DOB:

Pregnancy History: Number of (including and ): Number of Babies: Term: Prete rm: Miscarriages: ---- Date of Birth Gestational Age Hours in Labor Birth Weight Sex Type of Delivery Anesthesia Early Labor?

Any complication with any ? 0No Oves, explain------

Social History

Do you smoke? 0No Oves, how much? Years since started?

Do you drink? D No Oves, how much and how often?

Do you use recreational drugs? Oves, what and how much? ------

What is your highest level of education? 0Grade School 0High School Ocollege Oother

Are you working now? D No Dves, what is your job?

Are you: Osingle 0Married 0Divorced Dwidowed Oother:

Onset of sexual activity before 16 years of age? 0No Oves

Five or more sexual partners in your lifetime? 0No Oves

History of sexually transmitted disease? 0No Oves, what?

History of sexual abuse?

Have you had a mammogram? 0No Dves, when? Result: ______

Have you had a colonoscopy? 0No Dves, when? Result:______

Have you had a DEXA scan? 0No Dves, when? Result: ______(Bone Density) Review of Systems

Please mark yes(circle, check or X} for any current symptoms you may have.

CONSTITUTIONAL RESPIRATORY INTEGUMENT Weight gain Shortness of breath Rash YES Weight loss Chronic cough Itching YES Fatigue Wheezing Abnormal hair growth YES Hot flashes Pain with deep breathing Night sweats YES NO MUSCULOSKELETAL NEUROLOGIC Muscle pain YES EYES Dizziness YES Joint pain YES Double vision Seizures YES Muscular weakness YES Blurred vision Memory loss YES Numbness YES ENDOCRINE HENT Abnormal thirst YES Sore throat YES NO GASTROINTESTINAL Loss of hair YES Headaches YES NO Nausea Cold intolerance YES Nasal congestion YES NO Vomiting Heat intolerance YES Ringing in ears YES NO Constipation Sinus problems YES NO Diarrhea PSYCHIATRIC Dental problems YES NO Blood in stools Anxiety YES Heartburn Stress YES BREAST Depression YES Lumps YES NO GENITOURINARY Suicidal ideation YES Tenderness YES NO Urgency I Swelling YES NO Frequency HEME-LYMPH Redness YES NO Painful urination YES NO Easy bruising YES NO Nipple discharge YES NO Blood in urine YES NO Easy bleeding YES NO Night time urination YES NO Enlarged lymph node YES NO CARDIOVASCULAR Incontinence YES NO Lightheadedness YES NO Chest pain YES NO Heavy periods YES NO Blood clotting YES NO Irregular heart beats Irregular periods abnormality Leg swelling Painful periods Rapid heart rate Painful intercourse ALLERIC-IMMUNOLOGIC Blood clot Bleeding with intercourse Seasonal allergies ~ ~ Shortness of breath Significant PMS Allergic dermatitis ~ ~ on exertion Decreased sex drive YES NO

The above information is accurate to the best of my knowledge.

Patient Signature Date

Patient Name (Print) DOB Risk Assessment for Hereditary Cancer Syndromes Patient Name: Date of Birth: Date Physician ______Our clinic is dedicated to improving your quality of care, committed to your health, and helping with cancer prevention. To best serve you, we need a detailed personal and family cancer history.

Please consider the following Family Members when completing this form: (Blood Relatives Only) • Mother, Father, Sister, Brother, Children: (1st degree relatives) • Aunt, Uncle, Grandmother, Grandfather, Grandchild, Niece, Nephew, Half Siblings: (2"d degree relatives) • Cousins, Great Grandparent, Great Aunt, Great Uncle: (3'd degree relatives)

YOUR FAMILY'S Cancer History (Please be thorough and accurate. Please include BIOLOGICAL FAMILY ONLY)

CANCER YOU PARENTS/ SIBLINGS/ AGE MOTHER'S SIDE AGE FATHER'S SIDE AGE (age) CHILDREN DY /f.S EXAMPLE: '8RE.4sr S3 ON Ct'lNCER 61

0 y BREAST CANCER ON

0 Y OVARIAN CANCER ON

DY COLON/RECTAL CANCER ON

DY UTERINE/ENDOMETRIAL ON CANCER

DY OTHER CANCER{S) ON {SPECIFY) :

DY D N Are you of Jewish descent? What is your Ancestry: DY D N Have you or anyone in your family had genetic testing for a hereditary cancer syndrome? If yes, please explain:

Cancer Risk Assessment Review and Counseling

Patient's Signature: ______Date: ______Health Care Provider's Signature: Date: For Office Use Only: Patient offered hereditary cancer genetic testing? DYES D NO D ACCEPTED D DECLINED (patient signature below) Informed Refusal Documentation My provider, has recommended the BRACAnaylsis and/or Colaris and/or myRISI< genetic test based on my personal and/or family history of cancer. He/She has explained to me the potential benefits of the genetic test and the risks of not consenting to the genetic test. Despite my provider's recommendation, I decline to consent to the genetic test. Signature of patient for informed refusal ______For Office Use Only: Hereditary Breast and Ovarian Cancer Syndrome Lynch Syndrome Breast cancer diagnosed at or under age 4S* 1 Colon, rectal or uterine cancer diagnosed at or under age SO* Ovarian cancer at any age* 2 or more w/ a Lynch syndrome cancer****, 1 before the age of SO and 1 being 2 primary breast cancers in the same person w/ 1 diagnosed at or under age colon, rectal or uterine cancer** SO** 3 or more w/ a Lynch syndrome cancer**** at any age and one being colon, rectal 2 relatives same side of the family w/ breast cancer, 1 diagnosed at or under or uterine cancer** age SO** 3 or more of the following cancers at any age on the same side of the family: *Self, 1", 2°• degree family members breast, ovarian, pancreatic, prostate** **Self, 1", 2°•, or 3•• degree family members Triple negative breast cancer at or under the age of 60* ***HBOC associated cancers: Breast, ovarian, pancreatic Male breast cancer* ****Lynch associated cancers: Colon, uterine, gastric, ovarian, ureter/renal pelvis, Ashkenazi Jewish ancestry with an HBOC*** associated cancer* biliary tract, small bowel, pancreas, brain, sebaceous adenomas Optional Prenatal Screening

*Your provider will answer any questions at your appointment. You may also sign this form at that time.

Optional Prenatal screening testing: While pregnancy is a time of great joy for most parents, it may also be a time of some anxiety. A common question that many parents i!Sk is; "will my baby be normal?" Unfortunately there is no one test that will rule out all birth defects and problems. The following is an overview of the testing that we commonly offer. Your health care provider will answer any questions that you have about these or other tests.

A. Non-invasive testing: This category of testing has evolved over the years. These tests all involve maternal blood samplings and/or ultrasound and none of them are known to be associated with any risks. Insurance usually covers the cost of these tests. but it is your responsibility to check with your own insurance policy to be certain of coverage for any testing. These are the tests that we curre·ntly offer to fill pregnant women:

1. Serum Screening: This is a blood test on the mother that is done any time after 10 weeks in the pregnancy. It is usually approximately 99% accurate in detecting such as , Trisomies 13 and 18, along with sex chromosome abnormalities; with a low false positive rate. This testing can also predict the gender of your baby. Other types of serum testing may be able to detect other problems such as maternal carrier status for Cystic Fibrosis. Fragile X syndrbme (an inherited mental disability) and other carrier states. The results of these tests are usually available in 2 weeks. 2. Integrated First Trimester Nuchal Screening:_ This test consists of an Ultrasound exam at 11-13 weeks along with maternal blood testing. This test is approximately 95% accurate in detecting trisomies with a low false positive rate, and it can also help to identify babies that might have a problem with their heart, spine or some of the other .basic anatomy that can be seen at around 12 weeks. The ultrasound portion of this test is available immediately and the remainder of the result is usually available within 2 weeks. Gender is not identified on this test but you will usually have an ultrasound later (20-22 weeks) that will show gender if you desire. Tests 1&2 may be done together. 3. AFP/Quad screen. These are older maternal blood tests that are less accurate and have a higher false positive rate but they can done later, at 16-20 weeks in pregnancy. This test can screen for a NTD (Neural Tube Defect) which is an opening in the baby's spine, although the spine will probably be assessed at the 20-22 week ultrasound examination. If tests 1or2 are done. then only the AFP is offered: which screens for a NTD or opening in the baby's spine.

B. invasive testing: qr CVS are tests where a needle is inserted into the to obtain fluid or cells. These tests are very accurate but they are always associated with a small risk of miscarriage related to the procedure. These tests are generally reserved for very high risk situations, or they may be offered when other testing has indicated a possible problem. While they still may be appropriate for testing in special situations, less invasive testing is now the option that most patients prefer.

Ple;:ise check one box and circle the appropriate information. Piease print your name, sign and date below.

_I decline all forms of optional genetic counselling and testing. This is primarily because: (Circle one or write in)

_the information would not change my plans,_ I would not terminate a pregnancy for any reason or~~~~~~~~~~-'-~~~~~~~~~~~~~~~~~~~~~~~~~~

_I am interested in the following optional testing: (Circle only those that apply):_ Invasive testing

_Non-Invasive: 1. Serum Screening 2. Integrated First Trimester Nuchal Screen 3. AFP/QUAD screening

Print name Sign name Date

Witness Date Chart# Cheyenne

2301 House Avenue • ~o ~eyenne,@9,0~0~-5216, F>x #' (307) 773-0795 GENERAL ULTRASOUND CONSENT FORM

It has been recommended by your health care provider that you undergo an ultrasound examination. An ultrasound image is created from reflected echoes, using sound waves generated by the ultrasound equipment. No radiation is released during ultrasound procedures, and there is no known damage prod4ced to tissues or to a baby during a diagnostic ultrasound procedure. Although exten~ive research has shown ultrasound to be safe, it is wise to use ultrasound only when medically indicated, and not for entertainment purposes, since we can never be completely sure that some side effect will not be discovered in the future.

OBSTETRIC ULTRASOUND: Ultrasound can be used in pregnancy to determine specific details including, but not limited to: your due date, if you are having more than one baby, how well the baby is growlng, how much fluid is around the baby, and if the placenta and/or baby are in the correct position. At approximately 22 weeks into your pregnancy, a fetal survey is usually performed which adds additional information about the health of the baby, including looking at some of the fetal anatomy. It may sometimes be difficult to visualize structures due to fetal position, gestational age, variations within individual anatomy and body size. Follow up examinations may become necessary to look at structures which could not be visualized during the initial examination, or to follow up on potential problems.

Depending upon the baby's position and gestational age, we can tell you what sex we think the baby will be. Please keep in mind that ultrasound is not 100% accurate in fetal sex determination.

An ultrasound examination is not capable of detecting all possible birth defects, and this examination is not looking for all possible birth defects. Even if the ultrasound examination seems to be normal, we cannot give you a guarantee of a normal baby, free from birth defects. If we do see something of concern, however, it is possible to give you options and information and help you to make informed de.cisior'ls. The infdrmation obtained during the ultrasound examination, while not infallible, can help our office take better care of you and your baby.

GYNECOLOGIC ULTRASOUND: Likewise, ultrasound is helpful in evaluating the female pelvic organs including the uterus and ovaries. Ultrasound is not infallible, and it will not diagnose all conditions including cancers. It may sometimes be difficult to visualize structures due to variations within individual anatomy and body size. The ultrasound examination will probably give your health care provider additional information concerning your pelvic anatomy that may be of benefit in counseling you, or offering you options about your gynecologic care.

We as!< that you sign this consent form to acknowledge that your health care provider has discussed these ideas with you and also that you have had a chance to read and question this information, and that you give your unconditional permis~ion for the_examinat.ion. '. . · ·

Most of the time, your insurance is likely to cover the cost of the ultrasound examination that your doctor or health care provider has recommended. If the cost is not covered, you will become responsible for the charges, or possibly a portion bf the charges, which are not covered. If the ultrasound examination is not fully covered, you will need to make arrangements in our business office for a payment or a payment plan.

I have read this entire document. All of my questions have been answered and I voluntarily and --- knowingly elect to undergo all of the recommended ultrasound examinations during this pregnancy or during my gynecologic care.

I hav~ been informed that I could choose to have my ultrasound performed at sites other than Cheyenne OB/GYN, and I have also been informed that Cheyenne 08/GYN has the only AIUM accredited ultrasound facility in the state of Wyoming.

Signature Date

Witness Date

[US con s(09),6] Rev. 03/10