Obgyn Katy TX: Experienced Obgyn Specialist in TX

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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

*Home Address :					City
	State		Zip		Apt#

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

Emp/School Address :					City
	State		Zip

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

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

New Patient Registration

General Information

Patient History

Financial Responsibility

Acknowledgement of Receipt of Notice of Privacy Practices

*Email address :
	I am aware that periodically, I may receive e-mails from Jenkins Ob/Gyn and Reproductive Medicine.

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

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.

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

List all surgeries -
	Type of surgery	Approximate Date		Type of Surgery	Approximate Date
1.			2.
3.			4.
5.			6.

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:		Treatment?
Have you completed the HPV vaccine series (Gardasil)?	Yes No

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?

Date of last Pap Smear:		Results:
Date of last Mammogram:		Results:
Date of last Bone Density:		Results:

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


*	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.


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