PATIENT INFORMATION (Please Print) Patient First Middle Initial Last. Birthdate: / / Patient Financially Responsible Yes No

Transcription

1 PATIENT INFORMATION (Please Print) Date: Patient First Middle Initial Last Birthdate: / / Patient Financially Responsible Yes No Marital Status: Address: City: State: Zip Code: Primary Phone: ( ) (Circle One) Cell Home Work Other Secondary Phone: ( ) (Circle One) Cell Home Work Other By supplying your , you can gain access to your CUC Online Chart Do not have Have, but do not wish to provide Address: Prefer Contact By: (Circle One) Phone Text (Phone Carrier) Male Female Social Security Number: - - Referring Physician: Primary Care Physician: Employer: City, State, Zip Code: PRIMARY INSURANCE PLAN NAME: Please indicate: PPO HMO Medicare Self Insured Insured Name If other than Patient: Birthdate: / / Relationship to Patient: SECONDARY INSURANCE PLAN NAME: Please indicate: PPO HMO Medicare Self Insured Insured Name If other than Patient: Birthdate: / / Relationship to Patient: IN CASE OF EMERGENCY OR INABILITY TO REACH PATIENT PLEASE CALL: Name: Phone:( ) Relationship: Would you like this person to coordinate all care, including scheduling for you? Yes No

2 Patient First Last Date of Birth: / / NOTICE OF PRIVACY PRACTICE ACKNOWLEDGEMENT I acknowledge that I have been made aware of CUC s Notice of Privacy Practices, which is posted on their website, as well as available upon request in their office. I Place No Restrictions Restrict all of my Protected Health Information, except for the following individuals: Name: Relationship: Date of Birth: Name: Relationship: Date of Birth: NOTICE OF INSURANCE RELEASE OF INFORMATION AND AUTHORIZATION FOR PAYMENT I authorize the release of any medical or other information acquired in the course of my examination or treatment to insurance carriers. I authorize payment of medical benefits direct to Comprehensive Urologic Care for medical/surgical services rendered to me or my dependents. I understand that it is my responsibility to satisfy any payment obligations required by my insurance carrier at the time of service and am financially responsible for any services not covered by my insurance carrier. ACKNOWLEDGEMENT OF OFFICE POLICIES I acknowledge that I have been made aware of CUC s Office Policies, which is posted on their website, as well as available upon request in their office. Signature of Patient or Legal Guardian X Date:

3 Name: Date of Birth: M F Today s Date: Primary Care MD: Referring MD: Past Medical History (Check any illnesses and tell us when they occurred). Anemia Heart Attack (MI) Arthritis Hepatitis Asthma Hypertension (High Blood Pressure) Atrial Fibrillation Hypothyroidism Breast Cancer (Female) Irritable Bowel Syndrome Coronary Artery Disease Migraines COPD High Cholesterol Chest Pains (Angina) Osteoporosis Crohn s Disease Paraplegia Depression Quadriplegia Diabetes Seizures Diverticulosis Spine Problems/Pain Gout Stroke/CVA GERD Past Surgery (Check past surgeries and tell us when they occurred). Amputation Kidney/Ureter Stone (Basketing) Angioplasty Kidney/Ureter Stone (ESWL) Appendectomy Nephrectomy AV Fistula Orthopedic Surgery Back Surgery Peripheral Bypass Surgery Cardiac Bypass Prostate Surgery (Greenlight Laser) (male) Colon Resection Prostate Surgery (Microwave) (male) Gall Bladder Removal Prostate Surgery (TUNA) (male) Gastric Bypass Prostate Surgery (TURP) (male) Hernia Repair Radiation of Prostate (male) Hysterectomy (Female) Radical Prostatectomy (male) Mesh Hernia Repair Small Bowel Resection

4 Past Urologic History (Check any illnesses and tell us when they occurred). Bladder Cancer Prostate Cancer (male) Enlarged Prostate (BPH) (male) Prostatitis (male) Impotence (male) Renal Insufficiency / Failure Kidney Cancer Urinary Incontinence Kidney Cyst Urinary Tract Infections (UTI) Kidney Stones Vasectomy (male) Family History: Check Box(es) for any illnesses in your immediate family. Condition Father Mother Brother Sister Family Asthma Bleeding Disorder Breast Cancer Diabetes Enlarged Prostate Heart Disease High Blood Pressure Kidney Stones Lung Cancer Mental Illness Prostate Cancer Social History Do you smoke? Yes No How many packs/day? Past Smoking? Yes No Do you Drink? Yes No How much? Past Drinking? Yes No (Socially / Occasionally / Heavily / Recovering Alcoholic) Living at? Home Illicit drug use? Yes No Current Medications (Please list all medications and dosage). Medicines Strength Dosage Duration Notes _

5 Do you currently have any problems related to the following? Check applicable box if yes. Constitutional Gastrointestinal Neurological Fever Abdominal Tremors Chills Nausea/Vomiting Dizzy Spells Fatigue Indigestion/Heartburn Memory Problems Weight Loss Loss of Appetite Seizures Eyes Endocrine Psychiatric Blurred Vision Excessive Thirst Depression Double Vision Hot/Cold Intolerance Anxiety Glaucoma Hot Flashes Irritable Ear/Nose/Throat/Mouth Integumentary Genitourinary Ear Infection Skin Rash Incontinence Sore Throat Boils Painful Urination Sinus Problems Persistent Itch Frequent Urination Cardiovascular Hematologic/Lymphatic Reproductive (Male) Chest Pain Abnormal Bruising Erection Problems Varicose Veins Enlarged Lymph Nodes Ejaculation Problems Palpitations/High BP Anemia Infertility Respiratory Musculoskeletal Reproductive (Female) Wheezing Joint Pain Menopause Frequent Cough Neck/Back Pain Vaginal Deliveries # Shortness of Breath Bone Pain Irregular Periods Notes/Other: Known Allergies? None Known Penicillin (eg. Pen VK, Amoxicillin, Augmentin) Sulfa (eg. Septra, Bactrim) Cephalosporins (eg. Keflex, Duricef, Ceftin, Ceclor) Macrobid (Nitrofurantoin) Cipro Levaquin Tetracycline Latex Peanuts Shell Fish Iodine Demerol Morphine Codeine Any Other: