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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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_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ CONTINUED ON NEXT PAGE Medical history: Illness Duration _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Surgical history: Operation Year _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Medications: Medicine Dose Frequency _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ FAMILY MEDICAL HISTORY List any serious medical conditions and the relationship of that family member to you. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 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 ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ CONTINUED ON NEXT PAGE 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:____________________________________________________________
