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Name: ____________________________________ Today’s Date: _______________________ Date of Birth: ______________________________ Age:_____________ Primary Care or Referring Physician: _________________ Pharmacy: __________________________ Reason for Visit: (if you are here for a Re-check, please specify the reason.) __________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Medical Problems: Heart Disease High Blood Pressure Diabetes Stroke Emphysema Cancer (type)____________________________ Other: _____________________________________ Previous Surgeries or Procedures (including cystoscopy): _________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Medications (include homeopathic meds, herbal meds, & all vitamins you regularly take): ______ Medication Dosage Time Medication _______ Dosage Time_________ _________________ _______ ___________ _________________ _______ _____________ _________________ _______ ___________ _________________ _______ _____________ _________________ _______ ___________ _________________ _______ _____________ _________________ _______ ___________ _________________ _______ _____________ _________________ _______ ___________ _________________ _______ _____________ Allergies (including Anesthetics, IV contrast or dye): ______________________________________ ___________________________________________________________________________________ Family History including parents, siblings, and children (list family members & place a “D” behind any family members who are deceased): Bladder, Kidney, and/or Prostate Cancer (s)________________________________________________ Diabetes ________________________________ Heart Disease______________________________ High Blood pressure_______________________ Kidney Stones_____________________________ Other Cancer_____________________________ Other____________________________________ Social History: Marital Status ___________________________ Children _______________________________ Illicit/illegal drugs________________________ Occupation_____________________________ Alcohol – drinks/day_________________________________________________________________ Tobacco use-packs, cans, pipes/day______________________________ Years smoked____________ Caffeine-What kind(s) and how much____________________________________________________ Physician’s signature: ________________________________________________________________ Name: ______________________________ DOB:_______________________ Please circle all that apply for how you are feeling TODAY: General: Decreased appetite Increased appetite Chills Unexplained weight gain Unexplained weight loss Eyes: Blurred vision Changes to vision Allergy: Animal allergies Decreased vision Seasonal allergies Neurologic: Leg or arm weakness Endocrine: Diabetes Fevers X-ray dye Numbness/tingling Excessive thirst Headaches Night sweats Glasses Lidocaine/Novocaine Seizures Tremors Thyroid disorder Gastrointestinal: Abdominal pain Blood in stool Change in bowel habits Constipation Diarrhea Food intolerance Heartburn Jaundice Ulcers Nausea Vomiting Cardiovascular: Heart murmur Irregular heart beat Pain or cramps with exercise Palpitations Swelling/fluid retention Skin: Changing mole Musculoskeletal: Persistent itch Back pain Skin rash Joint pain Leg pain Ears, Nose, Mouth and Throat: Ear infection Muscle weakness Hearing problems Nosebleeds Sinus problems Genito-Urinary: Bedwetting Blood in urine Burning with urination Dribbling urine Leaking urine Urinating at night Urgency Frequent urination History of urinary tract infections Respiratory: Coughing up blood Hematologic/Lymphatic: Anemia Easy bruising Psychiatric: Anxiety Depression Difficulty breathing when flat Shortness of breath Easy bleeding Blood transfusions Wheezing Blood clotting problems Nervousness Physician’s signature: _______________________________________ Date: __________________ PATIENT REGISTRATION Lewis & Clark Urology, Ltd. Name: Maiden Name: Street Address: PO Box #: City: State: Date of Birth: Age: Social Security #: Zip: Email: Sex: Marital Status (Circle One): M S D W Home Phone #: Family/Primary Physician: Cell Phone #: Referring Physician: Emergency Contacts: 1 - Name: _____________________________ Ph.# _______________________ Relationship:___________________ 2 - Next of Kin: _________________________Ph.#_______________________ Relationship: ___________________ Your Occupation: Employer: Employer Address: Work Phone #: Ext.: The Office Will Need Your Insurance Card(s) To Make A Copy.Please make us aware of your Co-Pay & make payment at the time of each visit-CoPay amt.$_______ Primary Insurance: Policyholder Date of Birth: Policyholder: Sex: Policy #: Secondary Insurance: Policyholder Date of Birth: Group#: Policyholder: Sex: Policy #: Group#: I authorize my attending physician to release medical information necessary to determine benefits payable under this claim. I authorize benefits to be paid directly to the physician. I understand that I am responsible for this bill, regardless of insurance. * YES / NO - If you have an answering machine at home/cell//work, may we leave a message for you on that machine? * YES / NO - May we mail to your home items related to your treatment at our office (ex: test / lab results)? * YES / NO - Can we release medical info. to your spouse and / or other family members? X Signature ______________________________________________ Date _________________ Billing Information-Responsible Party (Please fill out this information if it is different from above) Name:_________________________ Address:_______________________________________________ Social Security #_______________________________ Date of Birth______________________________ Relationship to patient (Circle one): Parent Spouse Guardian