Patient Forms

Below are some patient forms that may be downloaded and filled out electronically (or printed and filled out by hand) prior to coming to your appointment.

First time patients at AWH or patients returning after one year:

Please access the “All Patients” form links below. Review the Patient Rights and the HIPAA Notice pages - these may be printed out and kept as a reference. The following list includes forms that need to be completed prior to your appointment:

• Demographics Form/ HIPPA Privacy Form – this form is for your general information (name, address, etc.) and your insurance information.

• Health History Form – informs your provider of your health history, your current medications, your allergies, and any current symptoms.

Additional form for Prenatal Patients only:

• Genetic Questionnaire – helps you and your provider determine what, if any, tests are necessary to rule out genetic abnormalities in your baby.

• Urogynecology Questionnaire – a health history questionnaire that is specific to urogynecology (pelvic organ prolapse or urinary incontinence.

Additional forms for Urogynecology:

• Voiding Diary – helps Dr. Mitchell-Springer or Dr. Ostrom determine your level incontinence or other urinary issues.

Please save all of the other forms from the “All Patients” folder to your computer and fill in the gray areas electronically. To fill in an area, simply click on the appropriate gray area and begin typing. (The non-gray areas of these forms are protected and cannot be changed.) Once filled out, please print your forms and bring them with you to your appointment. If you would prefer not to save them to your computer, then you can print out the forms and fill them out by hand and bring them with you to your appointment.

Please remember to bring your insurance card(s) and a photo ID (e.g. drivers license) to your appointment(s). Also, please contact your insurance company prior to your appointment(s) and find out the following: your deductible, your office visit co-pay, and your insurance preferred lab. If you go to a non-preferred lab, your insurance may not cover as much or any of the cost and the cost will become your responsibility.

Urogynecology (Prolapse or Incontinence)

Urogynecology Questionnaire
Urogynecology Voiding Diary
Urogynecology Letter

Prenatal Genetic Questionnaire
Genetic questionnaire

Infertility
Infertility History form

All Patients
Demographics/HIPAA Notice
Health History Form
HIPPA Notice
Patients Rights

Miscellaneous Forms
Release of Medical Records from AWH