PATIENT DATA (please complete and return to reception)

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PATIENT DATA (please complete and return to reception)
Name (Last, First, middle) ____________________________________________ Date ____/____/200__
Address __________________________________City _________________ State ______ Zip ________
Phone: Home # ______________________ Work # _________________ Cell # ____________________
Preferred contact number (return calls, lab results, etc.) ______________________________________
Preferred means of reporting test results (circle one): phone
Social Security # ______________________________
Date of Birth ____/____/____
Age_____
/ Email
Email Address __________________________
Sex: M / F
Employer ___________________________________
/ standard mail
Marital status: S / M / D / W
Occupation ___________________________
Emergency contact _____________________________ Phone # ______________ Relationship _______
Name of Primary Policy holder___________________________________ Date of Birth ____/____/____
Social Security # ______________________________ Employer ________________________________
Insurance Company Name ____________________________________ Policy # __________________
( ) HMO: referral needed
( ) PPO
Other: _____________________________________
Name of Secondary Policy holder ________________________________ Date of Birth ____/____/____
Social Security # ______________________________ Employer ________________________________
Secondary Insurance Company Name _______________________________ Policy # ______________
Pharmacy ___________________________________________ Phone # ________________________
Referral Physician_____________________________________ Phone # ________________________
Address _____________________________________________________________________________
Personal Physician____________________________________ Phone # _________________________
Address _____________________________________________________________________________
Referral Source (if not physician) ________________________________________________________
MEDICAL DATA SHEET
Name _____________________________________________________ Date _____________________
Your urological problems will be discussed in detail with your urologist. Please complete the following
pages in as much detail as possible as this background information will be very important to the
diagnosis and evaluation of your problem. The information you provide will be kept strictly confidential.
CHIEF COMPLAINT: What is the main reason for your visit today? Be sure to document when you
first noticed the problem, the location of the problem, how long the symptoms last, if the problem is
constant or variable, if anything seems to improve or worsen the problem, and the number (on a scale of
1-10, with 1 being least severe and 10 being most severe) that best describes the severity of the problem.
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Medical history:
Illness
Duration
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Surgical history:
Operation
Year
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Medications:
Medicine
Dose
Frequency
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FAMILY MEDICAL HISTORY
List any serious medical conditions and the relationship of that family member to you.
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Allergies to Medication: ________________________________________________________________
TOBACCO:  never smoked  former smoker  current smoker
 cigarettes  cigars  pipe  how much ______________
how many years ___________
ALCOHOL:  none
 rarely
RECREATIONAL DRUGS:
 No
 occasionally
 regularly
 Yes (please list): _________________________________
EXERCISE: note the type and frequency of your physical activities
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REVIEW OF SYSTEMS
Please check any of the following symptoms that are relevant to you and fill in the blanks where indicated. If you
do not have nay of the symptoms, check “no problems”.
Constitutional:
Respiratory:
 no problems
 no problems
Musculoskeletal:
 poor appetite
 cough
 no problems
 weight loss
 emphysema
 muscle weakness
weakness
 coughing blood
 arthritis
 fatigue
 asthma
 arthritis
 malaise
 shortness of breath
backache
 fever
 tuberculosis
 gout
 chills
 sweats
Skin:  no problems
Intestinal:
 pain
 no problems
 irregular moles
 change in bowel habit
 skin cancers
Eyes:  no problem s
 constipation
 rashes
 visual impairment
 nausea
 psoriasis
 glaucoma
 vomiting
 itching
 blurry vision
 blood in stool
 cataracts
 ulcers
Psychiatric:  no problems
 excessive gas
 substance abuse
 hepatitis
 anxiety
Ear/Nose/Throat:
 no problems
 heartburn
 depression
difficulty swallowing
 gallbladder problems
 mania
 hearing loss
 black stools
 alcoholism
 ringing in ear
 hiatal hernia
 insomnia
 sinus problems
 jaundice
 eating disorder
 hemorrhoids
 loss of smell
 hernia
Endocrine:  no problems
 hoarseness
 fecal incontinence
 diabetes
 swollen glands
 pituitary problems
 sore throat
 parathyroid problems
Neurological:
 frequent nosebleeds
 no problems
 thyroid problem
 mini strokes
 adrenal problems
 stroke
 ovarian problems
Heart/Blood Vessels:
 no problems
 numbness
 testes problems
 heart failure
 sciatica
 pancreatic problems
 palpitations
 difficulty walking
 excessive hunger
 arrhythmia
 excessive headaches
 sluggishness
 varicose veins
 vertigo
 excessive body hair
 high blood pressure
 tremors
 hyperactivity
 blocked carotid artery
 balance problems
 male –enlarged breast
angina
 weakness
 excessive thirst
 heart attack
 herniated disk
 nipple discharge
 buttock pain walking
 dizziness
 leg swelling
 seizures
Hematological:  no problems
 heart murmur
 fainting
 easy bruising
 blood clot in legs
 forgetfulness
 clotting problems
 blood clot in lungs
 paralysis
 bleeding tendency
 elevated cholesterol
 anemia
 aneurysm
 swollen lymph glands
 valve disease
 cancers
 mitral valve prolapse
CONTINUED ON NEXT PAGE
 visible blood in urine
 kidney infections
 bladder cancer
Urinary review of systems:
 no problems
Have you been diagnosed with or treated for:
 microscopic blood in urine  urinary infections  urinary retention
 kidney mass
 kidney obstruction  kidney stones
 painful urination
 burning with urination
 difficult urination
 frequent urination
 urgent urination
 night time urination –
# of times _____
 difficulty urinating at night
but not during the day
Leakage issues:
 on the way to the toilet
 with running water
 getting out of the car
 sitting quietly
 running
 laughing
 lifting
 playing sports
Do you have:
 foul smelling urine
 air in urine
 stool in urine
 cloudy urine
 urethral discharge
 flank pain
 groin pain
 putting the key in the door
 without realizing it
 during intercourse
 continuous leakage
 sneezing
 shouting
 bending
 hesitant stream
 need to strain to pass urine
 weak stream
 spraying/split stream
 stream starts/stops
 long time to empty
 incomplete emptying
 need to urinate twice or
more to empty
 in cold weather
 while sleeping
 with orgasm
 walking
 coughing
 climbing stairs
 standing
Obstetrical/gynecological (for females only):
Age at menstruation ______
Age at menopause ________
# Pregnancies ______
# Vaginal deliveries _______
# C-sections ______
# Miscarriages _______
# Abortions _______
Are you sexually active? Yes _____
No _____
Are you on Hormone replacement therapy? Yes _____
No _____
 no problems
 excessive menstrual bleeding
 bulge coming out of vagina
 lax vagina
 excessive menstrual cramping
 ovarian cysts
 loss of sexual desire
 uterine fibroids
 lubrication problems
 breast lumps
 painful intercourse
 breast pain
 inability to achieve orgasm
 breast discharge
 infertility
 breast cancer
 sexually transmitted disease
Males only:  no problems
 loss of sexual desire
 painful erections
 blood in semen
 inability to ejaculate
 infertility
 genital warts
 prostatitis
 elevated blood PSA
 lump on testicle
 undescended testes
 difficulty achieving an erection
 prolonged erections
 premature ejaculation
 painful ejaculation
sexually transmitted diseases
 foreskin difficulties
 prostate cancer
 abnormal urethral opening
 testes cancer
 absent testes
 difficulty maintaining an erection
 angulated erections
 delayed ejaculation
 decreased sensation with orgasm
 penile rash or skin abnormality
 prostate enlargement
 prostate nodule
 painful testicle
 testes hang too low
 shrinking penis
Any other unlisted problems:____________________________________________________________
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