THE UROLOGY GROUP
Barry S. Farber, M.D. & Thomas C. Pearson, M.D.
3850 S. National, Suite 320, Springfield, MO 65807
Patient Medical History
Name: _______________________________________________ Age: ______________ DOB: ______________
Family Physician: ___________________________________ Location: ________________________________
Referred by: ( ) Dr. ______________________________ ( ) Yellow Pages ( ) Friend/Family ( ) Insurance ( ) ER
( ) Other_____________________________
Preferred Pharmacy: _____________________________________ Location:____________________________
Current urology symptoms (circle): frequency, urgency, nocturia, dribbling, slow stream, loss of urinary control.
Do you have burning, hesitancy, sensation of incomplete emptying, straining to urinate, start and stop stream, blood in
urine, erectile dysfunction, other: __________________________________________________________
Medication allergies: __________________________________________________________________________
Medications/vitamins/herbals: __________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Surgical history (circle): cataract, carotid aortic aneurysm, heart bypass, angioplasty (stent), gallbladder, bladder,
prostate, kidney, uterus, ovary, colon, hernia, hip/knee replacement, knee scope, tubaligation, vasectomy, appendix Csection, back /neck, heart valve replacement, Pacemaker/Defibrillator, other: ____________________________
____________________________________________________________________________________________
Current medical conditions (circle): glaucoma, high blood pressure, diabetes (I or II), thyroid, asthma, emphysema,
COPD, multiple scleroses, HIV, gastric reflux, Parkinson’s, Crohn’s, ulcerative colitis, kidney failure/dialysis, sleep
apnea, oxygen dependent, coronary artery disease, endometriosis, other:_____________________________________
History of (circle): hepatitis, heart attack, heart murmur, tuberculosis, deep venue thrombosis, kidney stones,
seizures, pneumonia, stroke, cancer (type/when) __________________________, chemotherapy/radiation therapy,
MRSA, other:_________________________________________________________________________________
Family history:
Mother – living/deceased @age ______ cause ________________ medical problems:
__________________________________________________________________________
Father – living/deceased @age _______ cause ________________ medical problems:
__________________________________________________________________________
Sibling’s (how many) _____ Other family medical conditions: diabetes, heart attack, stroke,
prostate cancer, cancer, kidney stones, other ______________________________________
Social facts:
Marital status – single/married/divorced/widowed - Children ______Grandchildren _______
Tobacco usage - never/cigarettes/pipe/cigar/snuff/quit ______ years ago
Alcohol usage - never/occasionally _________ average drinks per week
Occupation ________________________________________________________________
Disabled/cause _____________________________________________________________
Exercise: walk/run/swim/other ____________________ times per week _______________
Hobbies __________________________________________________________________
THE UROLOGY GROUP
3850 S. National Ste 320
Springfield, MO 65807
NAME: ____________________________________________
DOB: ____________________
Please Circle Any Current Day-to-Day Symptoms
CONSTITUTIONAL:
Fever
Weight Loss
Chills
EYES:
Blurry Vision
Double vision
Cataracts
EAR NOSE MOUTH THROAT: Hearing Loss
Nasal Stuffiness
Sore Throat
CARDIOVASCULAR:
Chest Pains
Swollen Ankles
Irregular Heartbeat
RESPIRATORY:
Shortness of Breath
Wheezing
Chronic Cough
GASTROINTESTINAL:
Abdominal Pain
Nausea/Vomiting
Changes in Bowels
GENITOURINARY:
Incontinence
Painful Urination
Blood in Urine
MUSCULOSKELETAL:
Chronic Back Pain
Chronic Neck Pain
Sore Muscles
INTEGUMENTARY/SKIN:
Rash
Persistent Itch
Skin Cancer History
NEUROLOGICAL:
Numbness
Tingling
Dizziness
Abnormal Bleeding
Transfusion History
HEMATOLOGIC/LYMPHATIC: Swollen Glands
OTHER: _________________________________________________________________________________
IF YOU HAVE QUESTIONS FOR THE DOCTOR PLEASE LIST THEM BELOW
THE UROLOGY GROUP
Barry S. Farber, M.D. & Thomas C. Pearson, M.D.
3850 S. National, Suite 320, Springfield, MO 65807
Phone: 417-269-6944 or 800-832-8731
Fax 417-269-6947
Dear New Patient:
We welcome you as a patient to The Urology Group. Please find enclosed forms for you to review and complete. If
time allows return the completed forms in the enclosed envelope. Also, we ask that you bring your insurance card(s)
and your current medications in their original containers or a detailed list with you to this appointment.
Please note that male patients having difficulty urinating should arrive with a full bladder as a urine flow
measurement & specimen will be obtained. It is not necessary for female patients to have a full bladder, however,
they will be asked to provide a urine specimen, which will be checked for any problems. Bring a list of your current
medications, as the list will help to determine if any new medication prescribed would have an adverse drug-to-drug
interaction.
Our office hours are Monday through Friday, 8:30 a.m., to 4:30 p.m. If you have a medical or surgical problem
during office hours and you need to be seen by a doctor, please do not go to an Emergency Room or Emergency Care
without first calling the office. A physician is also on call for emergencies after hours and on weekends.
Dr. Farber & Dr. Pearson are participating Medicare providers. The Medicare recipient is responsible for their annual
deductible and 20% Medicare does not cover if a supplemental policy is not in place. The patient with standard
insurance coverage is responsible for the deductible, co-insurance &/or co-pay. This amount will be collected at the
time of service. The patient with an HMO plan is responsible for obtaining a referral from his/her primary care
physician (PCP) prior to every appointment with Dr. Farber or Dr. Pearson. If a referral is not obtained the patient is
responsible for all charges and payment is required at time of service. Private pay patients are required to pay in full
at the time of service. For convenience, we accept major credit cards.
There may be an occasion when emergency surgery could delay the doctor’s arrival to the office. We apologize for
any unforeseen inconvenience and appreciate your understanding.
If a delay occurs you may wait to see the doctor or reschedule your appointment.
We look forward to providing you with the highest-level medical and surgical urology care available. If you have any
questions or concerns, please feel free to call and we will assist you any way we can. Welcome to our office.
Barry S. Farber, M.D. & Thomas C. Pearson, M.D.
& Staff of The Urology Group