helen h.t. luong, m.d., f.a.c.o.g. jane k. hong, m.d., f.a.c.o.g. … · 2020-04-26 · helen h.t....

Helen H.T. Luong, M.D., F.A.C.O.G. Jane K. Hong, M.D., F.A.C.O.G. Women’s Care OB/GYN Medical Group, Inc. New Patient History I. Identifying Information Date: ______________________________ Name: ______________________________________________________ DOB: ______________________________ Reason for visit: ___________________________________________________________________________________ _________________________________________________________________________________________________ Age: _________ Name of Family Doctor: ________________________________________________________________ II. Medical History Please list all your current medical problems: None _________________________________________________________________________________________________ _________________________________________________________________________________________________ II. Surgical History List all surgeries you have had: None Date Operation Diagnosis ________________________________________________________________________________________________ ________________________________________________________________________________________________ III. General Health Do you drink alcohol? No Yes Do you smoke? No Yes If yes, how much? ____________________ Do you use recreational drugs or street drugs? No Yes Type____________________________ IV. Gynecologic History Date of last Pap Smear: ___________________________________ None Date of last mammogram: ___________________________________ None What was the FIRST day of your last menstrual period?: ___________________ Menopausal Hysterectomy What do you use to keep from getting pregnant? _____________________________________________________ V. Pregnancy history No pregnancies How many times have you been pregnant? ______ How many live births? ______ How many C-Sections? _______ How many vaginal deliveries? _______ How many miscarriages? _______ How many Ectopic Pregnancies? _______ How many abortions? _______ VI. Family history Adopted Have you or any family members ever had: Breast cancer: _________________________________ Asthma: ___________________________________ Ovarian cancer: ________________________________ Stroke: ____________________________________ Colon cancer: _________________________________ High cholesterol: _____________________________ Other cancers: _________________________________ Bleeding disorders: ___________________________ Diabetes: _____________________________________ Heart disease: _______________________________ High blood pressure: ____________________________ Anesthesia problems: _________________________ Patient Signature: ______________________________ Date: ______________________________________ 1019 W La Palma Ave, Suite B, Anaheim, CA 92801 ~ 714.535.8900 ~ Fax 714.778.1418

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Helen H.T. Luong, M.D., F.A.C.O.G. Jane K. Hong, M.D., F.A.C.O.G.

Women’s Care OB/GYN Medical Group, Inc. New Patient History

I. Identifying Information Date: ______________________________

Name: ______________________________________________________ DOB: ______________________________

Reason for visit: ___________________________________________________________________________________

_________________________________________________________________________________________________

Age: _________ Name of Family Doctor: ________________________________________________________________

II. Medical History Please list all your current medical problems: None

_________________________________________________________________________________________________

II. Surgical History List all surgeries you have had: None

Date Operation Diagnosis

________________________________________________________________________________________________

III. General Health

Do you drink alcohol? No Yes

Do you smoke? No Yes If yes, how much? ____________________

Do you use recreational drugs or street drugs? No Yes Type____________________________

IV. Gynecologic History

Date of last Pap Smear: ___________________________________ None

Date of last mammogram: ___________________________________ None

What was the FIRST day of your last menstrual period?: ___________________ Menopausal Hysterectomy

What do you use to keep from getting pregnant? _____________________________________________________

V. Pregnancy history No pregnancies

How many times have you been pregnant? ______ How many live births? ______ How many C-Sections? _______

How many vaginal deliveries? _______ How many miscarriages? _______ How many Ectopic Pregnancies? _______

How many abortions? _______

VI. Family history Adopted

Have you or any family members ever had: Breast cancer: _________________________________ Asthma: ___________________________________ Ovarian cancer: ________________________________ Stroke: ____________________________________ Colon cancer: _________________________________ High cholesterol: _____________________________ Other cancers: _________________________________ Bleeding disorders: ___________________________ Diabetes: _____________________________________ Heart disease: _______________________________ High blood pressure: ____________________________ Anesthesia problems: _________________________ Patient Signature: ______________________________ Date: ______________________________________

1019 W La Palma Ave, Suite B, Anaheim, CA 92801 ~ 714.535.8900 ~ Fax 714.778.1418

CURRICULUM VITAE 2 HARRY REICH, M.D., F.A.C.O.G. 2 NEW 2curriculum vitae 2 harry reich, m.d., f.a.c.o.g. 2 new 2 personal data 2 office address: 2 home address since 1978: 2 present

H.T. - APTRANSCO

H.T. Temple, MD Created March 2004; Revised December 2005

H.T. Katalog FIZ I, ANG, rek. 15,16

Endometrial Committee David Scott Miller, M.D., F.A.C.O.G., F.A.C.S. Director and Dallas Foundation Chair in Gynecologic Oncology Professor of Obstetrics

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LIGHT WEIGHT DIRECTORY ACCESS PROTOCOL Presented by Chaithra H.T

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