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855 346 8610
23535 Kingsland Boulevard, Katy, Texas 77494 | Directions
Obgyn Katy TX - Personal & Quality Care for Women in All Phases of Life
Personal & Quality
Care for Women in
All Phases of Life
T L Jenkins MD

New Patient Registration

Please note that it is important to fill in all the fields before submitting. Thank you.

General Information

*Patient Last Name :
Middle Name : *First Name :
*Home Address :
*Cell Phone#: ()--
Work Phone: ()---
Drivers Lic #:
*Email address :
I am aware that periodically, I may receive e-mails from Jenkins Ob/Gyn and Reproductive Medicine.
Check One: Employed F/T Student P/T Student Unemployed Marital Status: Single Married Other

Patient Information -
Employer/School: SS#:
Date of Birth:
Emp/School Address : City

Spouse/Parent (If minor) Information -
His/Her Name: SS#:
Date of Birth:
Cell Phone#: ()---

Emergency Contact Details -
His/Her Name: Phone Number: ()--

Relative or Friend not living at same address: -
His/Her Name: Relationship: Phone Number: ()--
Address : City

Primary Insurance - Secondary Insurance -
Insurance Co: Insurance Co:
Policy/ ID #: Policy/ ID #:
Group #: Group #:
Assignment of Insurance Benefits and Authorization to Release Information -
* I authorize payment of medical benefits to T.L. Jenkins, M.D., P.A. for any and all services not paid in full at the time those services are rendered. I authorize T.L. Jenkins, M.D, P.A. to release any medical information as may be necessary for the completion of my insurance claims to any insurance carrier, health or hospital plan.

Patient History

Select All that Apply -
Arthritis Asthma Diabetes Heart Attack
Heart Murmur Hepatitis High Blood Pressure Breast Problems
High Cholesterol Intestinal Bleeding Kidney Infection Kidney Stone
Pneumonia Migraine Headaches Mitral Valve Prolapse Neurological Disease
Osteoporosis Paralysis Rheumatic Fever Thrombophlebitis
Thyroid Problems Other Medical Problems:
List all surgeries -
Type of surgery Approximate Date Type of Surgery Approximate Date

Number of: Pregnancies Deliveries Miscarriages Abortions Living children

Please list ALL previous pregnancies in chronological order:
Year Sex Wt Anesthesia Complications
Male Female Vaginal or Cesarean
Male Female Vaginal or Cesarean
Male Female Vaginal or Cesarean
Male Female Vaginal or Cesarean
Male Female Vaginal or Cesarean

Will you permit a blood transfusion for medical reasons? Yes No
Are your periods regular? Yes No Date of last menstrual period:
Any problems with periods? Yes No Present type of birth control:
Do you want to change birth control? Yes No To what?

With respect to your female organs, have you ever had: Select all that apply -
Abnormal bleeding Genital warts Chlamydia Gonorrhea
Syphilis Herpes Infection Tumor of the Uterus or Ovaries Infections of the Tubes or Ovaries
Tubal (Ectopic) Pregnancy Ovarian cyst Breast tumors Infertility issues

Have you ever had an abnormal Pap Smear? Yes No Date:
Have you completed the HPV vaccine series (Gardasil)? Yes No
*List all allergies to medications:

List all currently used medications -
Medication Name Dosage Medication Name Dosage

Genetic: If you or your husband are in the following categories, please respond -
If of African American or Indian descent, have you or your husband had Sickle Cell carrier testing? Yes No
If of Italian or Greek descent, have you or your husband had Thalassemia carrier testing? Yes No
If of Jewish descent, have you or your husband had Tay-Sachs carrier testing? Yes No

Social History -
Occupation: Race:
Do you drink alcohol? Yes No If yes, estimated number of drinks per week?
Do you smoke? Yes No If yes, how many packs a day?
Are you using any other drugs? Yes No Type:
Are you sexually active? Yes No Any difficulties or discomfort?

Family History: Is there a member of your family with a history of -
Cancer – Type: Who?
Congenital(Inherited) Disease Who?
Diabetes Who?
Heart Disease Who?
High Blood Pressure Who?
High Cholesterol Who?
Kidney Disease Who?
Mental Retardation Who?
Osteoporosis Who?
Twins Who?
Date of last Pap Smear:
Date of last Mammogram:
Date of last Bone Density:
Reason for today’s visit:

Primary care physician: Phone number: ()--
*Pharmacy name:
*Phone number: ()--

What changes have there been in your life recently?
How did you hear about us? Other :

*Signature of Patient, Parent or Guardian :

Financial Responsibility

* I have received, read and understand the Patient Financial Policy from T.L. Jenkins, M.D., P.A. and I further agree to be bound by the terms stated therein. I also understand and agree that T.L. Jenkins, M.D., P.A. may amend such terms from time to time.

Acknowledgement of Receipt of Notice of Privacy Practices

* I, the undersigned, hereby acknowledge the receipt of a copy of the Notice of Privacy Practices of T.L. Jenkins, M.D., P.A.

Date :
Name of Signee: Relationship: