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TEXOMA UROLOGY CENTER 5500 Kell West Blvd., Suite 200 & 300 * Wichita Falls, TX 76310 Phone (940) 689-UROL (8765) Fax (940) 689-8769 Phillip E. Dowd, M.D. J. Stephen Dryden, M.D. R. Kyle King, M.D. Michael W. Toulan, M.D. PATIENT HISTORY FORM Today’s Date______/______/______ Last Name__________________________ First Name_________________ Initial________ Date of Birth_____________________ Reason for today’s visit________________________________________________________ ____________________________________________________________________________ Location of Problem ______Abdomen ______Kidney _______Prostate ________________Other ______Bladder When did you first notice this problem?________________ MEDICATION LIST Please list all medications you are now taking including over the counter medications. ( If you are providing a separate list, please check here _______ ) Medication_________________ Strength________ How often do you take?_____________ Medication_________________ Strength________ How often do you take?_____________ Medication_________________ Strength________ How often do you take?_____________ Medication_________________ Strength________ How often do you take?_____________ Medication_________________ Strength________ How often do you take?_____________ Medication_________________ Strength________ How often do you take?_____________ MEDICINE ALLERGIES Are you allergic to iodine or dyes? ______ yes ______no Please list all medications you are allergic to. ____________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Please complete back of form…….. Texoma Urology Center Patient History Form Page 2 Patient: _________________________________________ PAST MEDICAL AND SOCIAL HISTORY Past Surgeries Year Illnesses Requiring Hospitalization ________________________________ ______ ______________________________ Year ______ ________________________________ ______ ______________________________ ______ ________________________________ ______ ______________________________ ______ Do you smoke? Yes_____ No_____ If yes, how much?___________ # years___ Year Quit_____ Do you drink? Yes_____ No_____ If yes, how much?___________________________________ Do you have any bleeding tendencies? Yes_____ No_____ Explain_________________________ Have you ever had a blood or plasma transfusion? _____Yes _____ No If yes, when__________ FAMILY HISTORY Please check and list any family history of serious illnesses or serious medical problems: Diabetes………____ Who? _________________ Parkinson’s Disease_____ Who?______________ Cancer………...____ Who? _________________ Stroke………………. _____ Who?______________ Heart Disease..____ Who? _________________ Other_________________ Who?______________ Other__________________ Who?______________ REVIEW OF SYMPTOMS Have you been diagnosed with any serious illness or medical problem? ____Yes ____ No Please explain:_________________________________________________________________________________ Are you diabetic? ____Yes ____No Additional comments:_________________________________________ Please check symptoms you currently have: HEAD, NOSE AND THROAT ____Recurrent Headaches ____Sinus Problems ____Chronic or Frequent Cough ____Ear Problems ____Eye Problems ____Enlarged Glands ____Recurrent Nosebleeds ____Hearing Problems ____Difficulty Swallowing Other _____________________ GASTRO-INTESTINAL ____Nausea or Vomiting ____Vomited Blood ____Abdominal Cramping ____Peptic Ulcer Disease ____Chronic Indigestion ____Kidney Stone(s) RESPIRATORY ____Shortness of Breath ____Chronic or Frequent Cough ____ Asthma ____Emphysema ____Wheezing ____Coughed up blood ____Other__________________ ____Other__________________ ____Other__________________ ____Colitis or other Bowel Disease ____Hemorrhoids or Rectal Disease ____Change in Bowel Movements ____Rectal Pain ____Rectal Bleeding FEMALE Last Menstrual Period ___________ Menopause? ___Yes ___No Have you had any of the following tests within the last 6 months? CARDIOVASCULAR ____Plebitis ____Leg Cramps ____Easy Bruising ____Swelling Hands ____Mitral Valve Prolapse ____Swelling Feet ____Blurred Vision ____Swelling Ankles ____Fainting Spells ____Tingling Hands ____Chest Pain ____Tingling Feet ____Heart Problems ____ Weakness/Hands ____Anemia ____Weakness/Feet ____Dizziness GENITOURINARY ____Pain on Urination ____Any Blood in Urine ____Problems Urinating ____Kidney Problems (explain)______________ ____Prostate Problems (explain)_____________ ____Previou Prostate Surgery_______________ Tubal Ligation? ____Yes ___No Year ______ WHERE? ____ X-Ray – Kidney ___________________________ ____ Cat Scan – Kidney / Abdomen ___________________________ ____ IVP (X-Ray with intravenous dye)___________________________ ____ PSA (Prostate Blood Test) ___________________________ WHEN? ______________ ______________ ______________ ______________
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