IMAGING POLICY. Please contact the facility where imaging was performed for information on how to obtain disk(s).

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1 IMAGING POLICY We request that you make arrangements to bring all radiology imaging (CT, MRI, ULTRASOUND) on a disk(s) with you to your appointment. Failure to do so may result in your appointment being cancelled or repeat imaging. Please contact the facility where imaging was performed for information on how to obtain disk(s). Department of Urology The Ohio State University Wexner Medical Center 915 Olentangy River Road, Suite 2000 Columbus, OH urology.osu.edu

2 READ AND COMPLETE BEFORE YOUR VISIT! 1) FILL OUT THIS FORM completely, and bring it with you. Even better fax or it before your appointment. Fax: (614) ) BRING ALL OF YOUR MEDICATIONS WITH YOU IN THEIR BOTTLES. This includes tablets, liquids, patches, inhalers, eye drops, injections, nonprescription (over-the-counter), vitamins, herbs, pills, and creams. Extended care facility residents should bring their current Medication Administration Record, NOT just a list of orders. 3) BRING, FAX, OR RECENT MEDICAL REPORTS: including most recent office notes, surgery reports, pathology reports, radiology reports and disc, EKG, stress test, heart echo, heart catheterization, breathing tests (PFTs, spirometry), and hospital discharge summaries. See above for fax number and/or address. You should be able to obtain these from your urologist, family doctor, the doctor who did the test, or the hospital where the test was done. Please list the complete names and telephone numbers of your doctors so that we may contact them. You do not need to obtain reports of tests done at The Ohio State Wexner Medical Center locations. We have access to those reports. page 1 of 5

3 Patient's Name: How would you describe your race? ADVERSE MEDICATION REACTIONS ( ALLERGIES ) List all medications, including x-ray dyes, to which you have had an allergy or a bad reaction. Describe the reaction, include the approximate date and how your took the medication (oral, injected, inhaled). MEDICATIONS List all of your medications. Include inhalers, patches, eye drops, vitamins, herbs and over-the-counter non-prescribed remedies. Include approximate time usually taken, e.g. breakfast, supper, bedtime. MEDICATION NAME DOSE (e.g. 50 mg) Time taken (breakfast, supper, bedtime) page 2 of 5

4 CANCER HISTORY: If you have cancer, list the type of cancer and any previous treatments you have had. Include any past surgery, chemotherapy, radiation or drug treatments. Use back of page if necessary. SURGERY-TRAUMA: List all prior surgeries and major injuries not related to cancer. Include approximate dates and describe any complications including nausea and vomiting after surgery. Use additional paper if necessary. MEDICAL HISTORY: List all of your chronic and current medical problems and diagnoses. Include all conditions for which you take medication. Include recent hospitalizations. Use back of page if necessary. page 3 of 5

5 FAMILY / GENETIC MEDICAL HISTORY Below list all of your immediate family members LIVING and DEAD. Include their approximate current age, or their age when they died. List their major medical problems, and the approximate age the medical problem started. List anyone in your family who has had CANCER of the BLADDER, KIDNEY, URETER, URETHRA, PENIS, PROSTATE or TESTICLE. If necessary, use the back of this page or additional paper. RELATION ALIVE? AGE MEDICAL PROBLEMS (for example: hypertension, (now or at death) cancer, diabetes, heart, lung or kidney) Mother Father Please provide us with your doctors full names and telephone numbers. Full Name Telephone # Town or City Urologist Cancer Doctor Family Doctor Heart Doctor Lung Doctor Other Doctor page 4 of 5

6 MORE QUESTIONS Did you ever smoke? Cigars? Yes NO How old were you when you started smoking? How old were you when you got to 1 pack a day? Pipe? Yes NO How old were you when you got to 2 packs a day? Chew? Yes NO How old were you when you quit? How often do you have a drink containing alcohol? (e.g. daily, weekly, monthly) How many drinks do you have on a typical day when you do drink alcohol? When did you most recently smoke marijuana? When did you most recently use cocaine or any other drug? When did you most recently inject any nonprescribed drug? What is the highest grade you finished in school? What kinds of work do you do now, and have you done in the past? Have you ever worked with rubbers, dyes or paints? ---- If, so for how long? Have you ever had a blood transfusion? --- If so, when? _ Have you ever received the drug cyclophosphamide (Cytoxan)? What problems do you have with urination? How many times do you get up to urinate in a usual night? Do you see blood in your urine? Do you have a history of having multiple urinary tract infections? How much weight have you gained or lost in the past month? (+ / -) _ Do you get a rash or swelling from rubber, for example after blowing up a balloon? Have you ever had a seizure? Have you ever had a stroke or a near stroke? Have you ever had phlebitis or blood clots in your legs, arms or lungs? Please circle the ONE following statement that BEST describes you. I can walk on level ground, non-stop for 20 minutes and cover 1 mile. I can walk for 20 minutes without stopping provided I walk slowly. I must stop and rest after 5-10 minutes. I must stop and rest going from room to room in the house. I am short of breath just sitting. page 5 of 5

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