TODAY S DATE DATE OF LAST PHYSICAL EXAM / / AGE: <Age> SOCIAL SECURITY NO: DATE OF BIRTH REFERRED BY

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1 New Patient Package TODAY S DATE DATE OF LAST PHYSICAL EXAM / / AGE: <Age> LAST NAME FIRST NAME MIDDLE SOCIAL SECURITY NO: DATE OF BIRTH REFERRED BY OCCUPATION PRIMARY CARE PHYSICIAN <Primary Care Physician-Name (Default)> CHIEF COMPLAINT: What is the main reason for your visit today: (Describe your problem in detail) Location of the Problem Abdomen Back Leg History of Present Illness (Urologic) Please answer the following questions Front Back Physician use only: (Comments/Notes) How long does the problem last? PAST MEDICAL & SOCIAL HISTORY List all serious illnesses in your immediate family (Examples: Diabetes, Tuberculosis, Cancer, Heart Disease, etc.) Father: Mother: Grandfather: Grandmother: Siblings: : List any PERSONAL past illnesses and/or surgeries & Date/Year: List Current Medications (if none, write none) Are you on special diet? Y N If yes, explain Do you smoke? Y N If yes, how much? Do you Drink? Y N If Yes, how much? Any Allergies? Y N If yes, what On a Scale of 1-10, with 10 being the most severe, circle the number that best describes the problem When did you first notice the problem? 2 days ago 2 weeks ago 1 month ago Does anything help or make the problem worse? Moving around Standing up Lying on my side Physician use only: (Comments/Notes) 30 minutes 1 hour Always present Is anything else occurring at the same time? Yes No If you answered yes, please explain. Nausea Rash Headaches Is the problem constant or variable? Dull then Sharp Very sharp then leaves Always there Does the problem interfere with your normal functions? Yes No If yes, please explain

2 MEDICAL HISTORY: Date/Year: MEDICAL HISTORY: Date/Year: SURGICAL HISTORY: Date/Year: SURGICAL HISTORY: Date/Year: LAST FLU VACCINATION: FAMILY HISTORY (Example.- Cancer (and type), Diabetes, Tuberculosis, High Blood Pressure, Heart Disease): Father: Paternal Grandfather: Paternal Grandmother: Mother: Maternal Grandfather: Maternal Grandmother: Siblings: Immediate Family:

3 CURRENT MEDICATIONS MEDICATION DOSE ALLERGIES PREFERRED PHARMACY: LOCATION:

4 How many times a day do you urinate (from the time you get up in the morning until you go to sleep at night)? How many time a night do you urinate (from when you go to sleep at night until you wake up in the morning)? Please Answer YES or NO To The Following: Do you have pain or burning when you urinate? Have you recently seen blood in your urine (Red Urine)? When you go to the bathroom, do you have to wait more than 5-10 seconds before you start to urinate? Is your urine stream weak or does it dribble? Does your stream slow down or stop in the middle instead of flowing continuously? Does your urine stream dribble a lot at the end? Do you strain or push to pass urine? Do you feel like your bladder empties completely? When you need to urinate, is the feeling intense or do you have a lot of urgency? Do you ever wet yourself before getting to the bathroom to urinate (even a drop or two?) Do you wet yourself after urinating? Do you ever wet yourself if you cough, sneeze, laugh, or when lifting something? Do you have pain in any of the following areas? a) In the area around your bladder (lower abdomen) b) In your sides c) In your back d) (MEN) in your testes e) (WOMEN) with intercourse

5 (Please answer Yes or No) Have you had fever or chills recently? Have you had an infection in your urine (bladder or kidney)? Have you ever had a sexually transmitted disease: gonorrhea (the clap), Chlamydia, Syphilis, Herpes, Genital Warts, or AIDS? If yes, please circle. Have you ever had kidney stones? Do you have any children? If so, how many? For MEN: Do you have erection problems? PAST HISTORY Have you ever been treated by a urologist before? If yes, when, by whom, and why? Have you ever had a catheter (tube), metal rod or instrument passed up into your urethra (urine channel)? Are you a free bleeder? (Do you bleed even without being cut or do you bleed for a long time if you are cut?) Do you take aspirins frequently (how many a month)?

6 REVIEW OF SYSTEMS Do you now have or have you had RECENTLY any problems related to the following systems Yes or No. Please explain any yes answers in the space provided. CONSTITUIONAL SYMPTOMS Fever/Chills Y N : Y N EYES Blurred Vision Y N Double Vision Y N Eye Pain Y N ALLERGIC / IMMUNOLOGIC Hay Fever Y N Drug Allergies Y N : Y N NEUROLOGICAL Tremors y N Dizzy Spells Y N Numbness/Tingling Y N Blood Clot(s) to lungs Y N Seizures Y N : Y N ENDOCRINE Excessive thirst Y N Too hot/cold Y N Tired/sluggish Y N : Y N GASTROINTESTINAL Abdominal Pain Y N Nausea/Vomiting Y N Indigestion/Heartburn Y N Difficulty swallowing Y N Constipation or Diarrhea Y N Hemorrhoids Y N Blood with vomiting Y N Blood in stool Y N : Y N CARDIOVASCULAR Chest pain Y N Varicose veins Y N High Blood Pressure Y N Swelling of ankles Y N : Y N YES EXPLAINATIONS: INTEGUMENTARY Skin rash Y N Boils Y N Persistent Itch Y N : Y N MUSCULOSKELETAL Joint pain Y N Neck pain Y N Back pain Y N : Y N EAR / NOSE / THROAT / MOUTH Ear infection(s) Y N Sore throat Y N Sinus problems Y N Difficulty hearing or deafness Y N Discharge from ear(s) Y N Nose bleeds Y N : Y N GENITOURINARY Urine retention Y N Painful Urination Y N Frequent Urination Y N : Y N RESPIRATORY Wheezing Y N Frequent cough Y N Shortness of breath Y N : Y N HEMATOLOGIC / LYMPHATIC Swollen glands Y N Blood clotting problems Y N : Y N PSYCHOLOGIC Are you satisfied with your life? Y N Do you feel severely depressed? Y N Have you considered suicide? Y N : Y N YES EXPLAINATIONS: Physician use only: (Comments/Notes)

7 Pocket Card Says Genitourinary Physical Examination Problem Expanded Detailed Comprehensive Focused Problem Focused Physical Examination System/Element System/Element System/Element System/Element Single Organ System Genitourinary 1+/1-5 1+/ /12+ Patient Name: Date: Physician Signature: shaded/all unshaded/1 Systems/Body Areas Bulleted Elements Constitutional Vital Signs: General Appearance Neurological/Psychiatric Orientation: Mood & Affect: Skin Inspection and/or Palpation Neck Neck: Thyroid Respiratory Respiratory Effort: Auscultation: Cardiovascular Auscultation: Peripheral: Lymphatic Palpation [Continue on next page.] Select any three (3) Vital Signs: Content of Work Physical Assessment Data BP(sitting) BP(Supine) T P R HT WT Development: Deformities: Nutrition: Grooming: Time Place Person Depression Anxiety Agitation Pale Jaundice Cyanosis Turgor Hydration Texture Rash Lesions Symmetry Swelling Tenderness Size Tenderness Nodules Labored Diaphragmatic Abdominal Rales Rhonchi Wheezes Rubs Rhythm: Murmurs Rubs : Swelling Varicosities Pedal Pulses Temperature Tenderness Two (2) or More Neck: Size Tenderness Axillae: Size Tenderness Groin: Size Tenderness : Size Tenderness

8 Gastrointestinal Abdomen: (Organs) Bladder, Kidney Hernia: Absent Liver and/or Spleen: Stool Specimen: Genitourinary (Male) Anus and Perineum: Scrotum: Epididymides: Testes: Urethral Meatus: Penis: Prostate: Seminal Vesicles: Sphincter Tone: Genitourinary (female) Breast: DRE: External Genitalia Urethral Meatus: Urethra: Bladder: Vagina Cervix: Uterus: Adnexa/Parametria: Anus and Perinuem: Comprehensive level requires documentation of all elements Mass: Size Sharp Consistency Tenderness: RUQ LUQ LLQ RLQ Rigidity Direct Rebound Inguinal RT Lt Femoral RT Lt Ventral Liver Spleen Size Tender Mass Size Tender Mass Not indicated Collected Comprehensive Level required documentation of all elements Fissures Edema Dimples Tenderness Lesions Rash Sebaceous Cyst Enlarged Indurated Tender Mass Spermatocele Tenderness Symmetry Hydrocele Rt Lt Mass Small Large Position Hypospadias Location Lesion Polyp Discharge Circumcised Phimosis Peyronie s Condylomata Lump Size 20 gr 30 gr 45 gr 60 gr 90 gr other Symmetry: RT>LT LT>RT Rubbery Firm Hard Boggy Nodules Irregular Symmetrical Tender Indurated Nodule Size Location Poor Hemorrhoids Mass Size Location Comprehensive level requires documentation of 7 of 11 elements Symmetrical RT>LT LT>RT Tender Nipple Discharge Mass Size Location Fixed Movable Tone Mass Hemorrhoids Hirsutism Lesion Caruncle Condylomata Rash Small Large Position: Retracted Hypospadias Discharge Tenderness Masses Scarring Mass Size Firm Soft Fullness Residual Empty Cystocele: Degree Rectocele: Degree Enterocele: Degree Inflamed Discharge Lesion: Size Location Size Irregular Position Mobility Consistency Decent Tenderness Ovaries Size Mass Movable Fixed Fissures Edema Dimples Tenderness

9 Name: Date of Birth: DATE: PHYSICAL EXAMINATION CONT Current/Recent Labs UA C&S BUN CREAT PSA Date SpGr: Ph: Protein: Glucose: Occ Blood: Ketones: Nitrates: DIAGNOSIS:

10 PLANNING/ORDER FORM Name: <Full Name> Date of Birth: <Date of Birth> DATE: <Date of Service> REFERRING PHYSICIAN: <Primary Referring Physician> LABS: IMAGING STUDIES: CCMS CATH URINE FOR UA FOLEY CT SCAN ABDOMEN (KIDNEYS) W & W/OUT IV CONT CATH CT PELVIS W & W/OUT IV CONT C&S CYTOLOGY MICRO RENAL U/S URINE CULTURE FOR C&S PELVIC U/S BLADDER W/ PRE VOID BUN (W/DISTENDED BLADDER) & POST VOID VOLUME & IF CREATININE MALE - INCLUDE PROSTATE (FOR SIZE / CONSISTENCY) PSA IMPOTENCE PANEL: OTHER: CBC FOUR (4) DAY VOIDING DIARY CMP UROFLOWMETRY (51741) THYROID FUNCTION TEST BLADDER SCAN W/PVR (51798) FREE & TOTAL TESTOSTERONE (early morning) BLADDER SCAN W/PRE & POST VOID (51798) PROLACTIN BLADDER / PELVIC ULTRASOUND LH US GUIDED PROSTATE BIOPSY (55700) COMPLETE QUESTIONNAIRE: AUA System Index/IPSS (Males Over 40) Sexual/Erectile Dysfunction Incontinence (Females) Infertility MEDICATION(S): GIVE INSTRUCTIONS FOR MEDICATIONS OTHER TREATMENT: OBTAIN PREVIOUS RECORDS: GIVE LITERATURE (SEE QUESTIONNAIRE LIST) CONSULTATION/REFERRAL TO: SEND CONSULTATION REPORT TO REFERRING PHYSICIAN OTHER: RETURN TO OFFICE: