Greater Houston OB/GYN – Memorial Hermann Tower

(713) 935-9791

929 Gessner Road, Suite 2150, Houston, TX 77024

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        • Meet our Team
          • Dr. Natalie Dodds
          • Camille V. Boon, M.D.
          • Ashley Hester, MD
          • Anne V. Gonzalez, M.D.
          • Dr. Krista K. Tejml M.D.
          • Kaitlin Papaioannou, PA-C
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        • Contact Us
        • Home
        • About
          • Our Practice
          • Billing
        • Meet our Team
          • Dr. Natalie Dodds
          • Camille V. Boon, M.D.
          • Ashley Hester, MD
          • Anne V. Gonzalez, M.D.
          • Dr. Krista K. Tejml M.D.
          • Kaitlin Papaioannou, PA-C
        • Services
        • Resources
          • Patient Forms
          • Medical Records Request
          • FMLA & Disability Forms
          • Website Links and Booklets
        • Contact Us

        Patient Information Form

        Patient Information Form

        Please complete this form as accurately as possible. Items marked required must be completed before submission.

        Step 1 of 4 – Basic Info

        25%

        Basic Information

        Tell us a little about yourself.
        Patient Name(Required)
        MM slash DD slash YYYY
        MM slash DD slash YYYY
        Marital Status

        Pharmacy Information

        Would you accept a blood transfusion if needed?

        Medical History

        Check any conditions that apply.
        Heart / Blood / Circulation
        General Medical Conditions
        Neurologic / Mental Health
        Cancer / Other Conditions
        Include prescriptions, over-the-counter medications, vitamins, and herbal remedies.
        Allergy Options

        Surgical History

        Past surgeries
        Date
        Surgery
         
        Add one row per surgery.

        Pregnancy History

        Pregnancy History Options
        Pregnancy history details
        Year
        Sex (M/F)
        Birth Weight
        Delivery Type
        Gestational Age
        Delivering Doctor
        Problems
         
        Include miscarriages, premature births, stillbirths, ectopics (tubal), and abortions. Add rows as needed.

        Gynecologic History

        MM slash DD slash YYYY
        Period length
        Periods are usually
        Flow is usually
        Are you sexually active?
        Any recent new partners?
        Sexual preference
        Current birth control method

        STD / Vaccine History

        Have you ever had any of these STDs?
        Have you received the Gardasil (HPV) vaccine?
        MM slash DD slash YYYY
        Did you receive all 3 doses?
        Gynecologic conditions

        Screening History

        MM slash DD slash YYYY
        Pap smear result
        Treatment needed for abnormal pap
        MM slash DD slash YYYY
        Mammogram result
        MM slash DD slash YYYY
        Bone density result
        MM slash DD slash YYYY
        Colonoscopy Options

        Family History

        Family history details
        Condition
        Relative / Age at Diagnosis / Status
         
        List close relatives and any relevant diagnoses.

        Social History

        Do you use alcohol?
        Do you use tobacco?
        Do you use street drugs?
        Do you exercise?
        Do you use caffeine?
        History of sexual abuse
        If yes, are you safe now?
        If yes, have you received counseling?
        History of physical abuse
        If yes, are you safe now?
        If yes, have you received counseling?
        History of emotional abuse
        If yes, are you safe now?
        If yes, have you received counseling?

        Acknowledgment

        Clear Signature
        MM slash DD slash YYYY

        Quick Contact

        Office : 713-935-9791
        Fax : 713-467-9709
        Email :[email protected]

        Office Hours

        Monday–Thursday:
        8:00am - 5:00pm

        Friday:
        8:00am - 12:00pm

        Quick Links

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        Location

        929 Gessner Road, Suite 2150
        Houston, TX 77024

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