Download Registration form - urology conditions, Lewis and Clark Urology Home

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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