Our Physicians
Dr. Rick Muckerman
Dr. George Ahlering
Dr. Christi Menges
About Us
Locations
Office
Where we operate
Where we deliver
Our Nurse Practioner
Practice history
Our Services
3-D ultrasound
Bone density testing
Gynecology services
In-office procedures
Mammography
OB services
Surgery Center procedures
Front Desk
Appointments
Insurance carriers
Patient Forms
New Patient Forms
DXA test (Bone density)
Medical History
Gynecology Visit
Disclose Information
Office policies
Patient Name:
Date:
OBSTETRICAL HISTORY
Pregnancy
Number
Delivery Date
Mo./Yr.
Full Term
Y/N
Birth Wt.
lbs/oz.
Sex
M/F
Vaginal/
C-Section
Epidural/
Complications
SURGICAL HISTORY
List any surgeries (Inpatient or Outpatient) that you have had.
Date of Surgery
Surgery Performed
Hospital Performed In
OTHER HOSPITAL ADMISSIONS
List any serious illnesses or other hospitalizations.
Year of Admission
Reason for Admission
Hospital