New Patient Information. Which Physician will you be seeing today? How did you hear about our practice?

Transcription

1 New Patient Information Which Physician will you be seeing today? How did you hear about our practice? Local Pharmacy Name: Pharmacy Phone #: Pharmacy Location/Address: Name Preferred Age: (Last) (First) (MI) Date of Birth: Sex: Social Security #: Marital Status: Race: Check one: White Black/African American Asian American Indian/Alaska Native Native Hawaiian/Pacific Islander Other Ethnicity: Hispanic or Latino Not Hispanic or Latino Primary Language: Address: Home# City State Zip Code Work #: Cell #: Preferred Communication: (Check One) Home Cell Work Address: EmployerName: Referring Physician: Phone: Primary Care Physician: Phone: Emergency Contact: Phone: Name of Spouse (or Parent if Minor): Spouse/ParentAddress: Spouse/Parent Phone #: Work: Cell: Spouse/Parent Date of Birth: Spouse/Parent Social Security#: Spouse/Parent Employer: Primary Insurance Company: Phone: Insured s SS# Policy Holder s Date of Birth: Secondary Insurance Company: Phone: Insured s SS# Policy Holder s Date of Birth: Initial Each Line and Sign Below: I authorize Lowcountry Urology Clinics, PA to release medical records to other physicians relating to my treatment and care. INSURANCE AUTHORIZATION AND ASSIGNMENT: I hereby authorize Lowcountry Urology Clinics, PA to furnish information to insurance carriers concerning my illness and treatment(s) and hereby assign to the physician all payment(s) for medical services rendered to myself or my dependents. I further understand that I am responsible for any balance not covered by insurance. I understand it is my responsibility to obtain insurance referrals from my primary care physician if required by my insurance. Signature of Patient or Authorized Person Date

2 Today s Date Date of Birth: Patient Name: Reason for Visit: Preferred Pharmacy Name: Pharmacy Phone #: Pharmacy Location/Address: Past Medical History (PMHx) Please Check All that Apply Anxiety Heart Disease Arthritis- Please Circle High Cholesterol Osteoarthritis High Blood Pressure Psoriatic Irritable Bowel Syndrome Rheumatoid Low Thyroid Cancer - type: High Thyroid Coronary Artery Disease (CAD) Chronic Obstructive Pulmonary Disease (COPD) Degenerative Disc Disease Seizure Depression HIV/Aids Diabetes (High Blood Sugar) Urologic History: Abdominal Pain Overactive Bladder Back Pain Prostate Cancer Bladder Displacement Prostatitis Blood in Urine Renal Failure Burning Urinary Frequency BPH Urinary Tract Infection (UTI) Difficult Voiding Elevated PSA Erectile Dysfunction Incontinence Kidney Disease Kidney Stones Waking to night/times Past Surgical History (PSHx) Urinary Retention Urinary Urgency Vaginal Discharge List Any Other Below: Please List Below Surgery/Date of Surgery: Please be sure to list dates of each surgery if there is more than one.

3 Medication List (Meds) Please List All Below Drug Dosage Frequency Reason for Medication Allergies Please List All Known Allergies to Medications: Yes No If yes please explain: Food Allergies: Yes No If yes please explain: Allergic to Latex? Yes No Any other Known Allergies? Please explain

4 Review of Systems Do you now or have you had any problems relating to these systems? Please circle "Y' for Yes and "N" for No Constitutional Symptoms Integumentary Fever Y N Skin Rash Y N Chills Y N Boils Y N Headaches Y N Persistent Itch Y N Other Other Eyes Y N Neurological Blurred Vision Y N Tremors Y N Double Vision Y N Dizzy Spells Y N Pain Y N Numbness/Tingling Y N Other Other Ear/Nose/Throat/Mouth Musculoskeletal Ear Infection Y N Joint Pain Y N Sore Throat Y N Neck Pain Y N Sinus Problems Y N Back Pain Y N Other Other Cardiovascular Endocrine Chest Pain Y N Excessive Thirst Y N Varicose Veins Y N Too hot/cold Y N High Blood Pressure Y N Tired/Sluggish Y N Other Other Respiratory Psychologic Wheezing Y N Are you satisfied with your life? Frequent Cough Y N Y N Shortness of Breath Y N Do you feel severely depressed? Other Y N Have you ever considered suicide? Gastrointestinal Y N Abdomen Pain Y N Hematological/Lymphatic Nausea/Vomiting Y N Swollen Glands Y N Indigestion/Heartburn Y N Blood Clotting Y N Other Other Genitourinary Allergic/Immunologic Urine Retention Y N Hay Fever Y N Painful Urination Y N Drug Allergies Y N Urinary Frequency Y N Other Other Physician Use Only: Physician: Date:

5 Family Medical History (FMHx) List relative with history of illness Diabetes Heart Disease High Blood Pressure Kidney Disease Vascular Disease Prostate Cancer Stroke Other Social History (SHx) Alcohol Use: Never Current Former # of Drinks per day Age Started: Age Stopped: Tobacco Use: Never Current Former # packs per day Age started Age Stopped: Drug Use: Do you use recreational drugs? Yes No If yes, explain Occupation: # of Children: Physician Notes:

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