Clarksville Urology Center* New Patient Urologic History Form
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- Derrick Carroll
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1 Clarksville Urology Center* New Patient Urologic History Form Patient s Name: (Last) (First) (MI) (Date) Age: DOB: Referring Dr: Primary Dr: Allergies: Are you allergic to: Latex Dye / IV Contrast Shellfish / Shrimp! I have no medication allergies Iodine / Betadine Tape / Adhesives Anesthetics Penicillin Sulfa Cipro / Levaquin Medication allergies: (List all) Medications Do you take any medications? Yes No Are you currently taking the following blood thinners?:! Aspirin!81 mg or!325 mg! Motrin! Aleve! Ibuprofen! Celebrex! Mobic!Other:! Coumadin! Warfarin! Plavix! Pradaxa! Xarelto! Eliquis! Heparin! Lovenox Please list all the medications you take with the dosage and frequency Medication: Dose: How Often: Please list all Vitamins & Supplements such as Vitamin E, Fish oil, Herbal preparation, Garlic, etc
2 Irregular heartbeat Carotid artery disease Congestive heart failure High blood pressure High cholesterol Heart attack Peripheral vascular disease Heart valvular disease Renal artery stenosis Heart disease Asthma Bronchitis COPD Cystic fibrosis Pneumonia Pulmonary embolism Sarcoidosis Sleep apnea Tuberculosis Cirrhosis Crohn s disease Heartburn/GERD Hepatitis B Hepatitis C Irritable bowel syndrome Peptic ulcer disease Ulcerative colitis Past & Present Medical Problems Diverticulosis Kidney failure Endometriosis Polycystic kidney disease Kidney stones Vesicoureteral reflux Kidney infections/uti Kidney obstruction Enlarged prostate/bph Prostate infection STD s Fibromyalgia Gout Osteoporosis Rheumatoid arthritis Polio Artificial joints Lupus Addison s Disease Cushing s disease Diabetes Hyperthyroidism Hypothyroidism Alzheimer s Bipolar Stroke Dementia Multiple sclerosis Myasthenia gravis Parkinson disease Seizures TIA Anemia Sickle cell anemia Blood clots HIV/AIDS Glaucoma Drug dependency Depression Bladder cancer Breast cancer Cervical cancer Colon cancer Kidney cancer Lung cancer Penile cancer Prostate cancer Skin cancer Testicular cancer Uterine cancer Cancer, Other: Other: Female history Number of pregnancies: Number of Deliveries: Vaginal C-Section Have you had a hysterectomy?! Yes When? Why? Have you had any prior bladder surgeries/when? Have you had a bladder tack/when? Have you had a sling/when? Surgical History Date: Surgery: Date: Surgery:
3 Family History (please indicate which family member) Urinary infections Bleeding disorders Heart disease Kidney stones Diabetes Bladder cancer Tobacco/ Alcohol History Prostate cancer Kidney cancer Other: Do you currently smoke?! Yes How much? Did you smoke in the past?! Yes How long? When did you quit? Do you drink alcohol?! Yes How many drinks per day? Do you use recreational drugs?! Yes Substances: What is the main reason for your visit today? Write in your own words on the lines provided: When did you first notice the problem? Location of the problem? (You may choose more than one location) Abdomen Pelvis Back Penis Groin Rectum Flank Bladder Genitalia On a scale of 1-10, with 10 being the most severe, circle the number that best describes the problem How long does the problem last? Is the problem: Constant Variable Seldom Does anything make the problem worse? Moving around Lying on side Standing up Other: Does anything make the problem better? Does the problem interfere with your normal activities?! Yes What testing have you had to evaluate your urological problem? I have had no tests to evaluate this problem X-ray Ultrasound CT scan Nuclear bone scan MRI Nuclear renal scan IVP Urine specimen Blood tests Cystoscopy Urodynamic Testing Other: Unsure Where was the test performed?
4 Do you have blood in the urine?!yes If no, have you ever had blood in the urine?!yes If yes: Every time I urinate Intermittently Painful Painless It occurs at the beginning of urination It occurs at the end of urination It occurs the entire urine stream Blood clots are passed in the urine Do you experience any of the following? Urinary urgency Urinary frequency Burning with urination Weak stream Straining to urinate Trouble starting stream Dribbling How many times do you wake up to urinate at night? Do you feel like your emptying your bladder completely?!yes Do you leak urine?!yes Is your leakage associated with the urge to urinate?!yes Is your leakage associated with coughing, laughing, jumping, sneezing, or exercising?!yes Do you wear protective pads?!yes How many Pads/day? Liners/day? Diapers/day? Other: Are they usually:! Dry!Moist!Wet!Soaked Men only: Do you have a problem with libido/desire?! Yes Do you have a problem achieving or maintaining an erection?! Yes Have you tried any medications for erectile dysfunction?! Yes Please indicate which medication(s) below:!viagra!cialis!levitra!staxyn!muse!bimix!trimix! VED!Other: Men & Women: Are there any other urologic issues you would like to discuss with Dr. DeLaurentis today?! Yes (Please explain:) Thank you for taking the time to complete your urological health questionnaire. Welcome to our practice! Dr. Dino DeLaurentis, DO, FACOS, PLC *CLARKSVILLE UROLOGY CENTER IS NOT A PARTNERSHIP
5 REVIEW OF SYSTEMS Name: Date: Please check only the problems that currently apply to you CONSTITUTIONAL EYES Fever Chills Weight gain Weight loss Blurred vision Vision loss EARS/ NOSE/ THROAT Hearing loss Sinus problems Difficulty swallowing Sore throat Dental problems Nose bleeds CARDIOVASCULAR Chest pain Palpitations Irregular heartbeat Swelling of feet/ extremities RESPIRATORY Shortness of breath Chronic cough Coughing up blood GASTROINTESTINAL Poor appetite Nausea Vomiting Diarrhea Constipation Abdominal pain Blood in stool Heartburn GENITOURINARY Blood in urine Leakage of urine Weak stream Frequency urination Urge to void suddenly Getting up at night to urinate Problems with erections Pain with intercourse Bladder pain Pelvic pain Burning with urination Frequent urine infections MUSCULOSKELETAL Back pain Joint pain Muscle aches INTEGUMENTARY/SKIN Rash Atypical moles Itchy skin NEUROLOGIC Numbness Weakness Dizziness HEMATOLOGIC/ LYMPHATIC Easy bruising Bleeding tendency Swollen lymph glands ENDOCRINE Excessive thirst Hot/cold Intolerance Hormone problems Fatigue ALLERGY Medication allergy Latex allergy Seasonal allergies PSYCHIATRIC Depression Anxiety **Healthcare provider only: The above systems have been reviewed by: Physician s initials
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Past Surgical History
Name: DOB: Check All That Apply Past Medical History o Anemia o Aneurysm o Asthma o Bipolar o Bleeding Disorder o Blood Clot o Brain Tumor o Bronchitis o Cancer o Crohn s Disease/Ulcerative Colitis o Depression
Tel: (312) Women s Integrated Fax: (312) Pelvic Health Program. 1.0: Basic Information. Preferred Language:
Tel: (312) 694-7337 Women s Integrated Fax: (312) 695-0156 Pelvic Health Program 1.0: Basic Information Date of Birth: / / Age: Home Address: Preferred Language: English Spanish Other: Email address: Preferred
PATIENT INFORMATION Please print clearly and complete all blanks
PATIENT INFORMATION Please print clearly and complete all blanks DATE: REFERRED BY: SEX: NAME: LAST FIRST MIDDLE BIRTHDATE: MAILING ADDRESS: CITY STATE ZIP TELEPHONE: CELL PHONE: WORK NUMBER: SS # MARITAL
Name: (Last), (First), (Middle) Date of Birth: SS: Left or Right Handed: Complete Address: Phone: Home: Cell: Work:
An Outpatient Department of PLEASE FILL OUT ALL INFORMATION COMPLETELY Date Completed Name: (Last), (First), (Middle) Date of Birth: SS: Left or Right Handed: Complete Address: Phone: Home: Cell: Work:
Florida Hospital Spine Center Patient Intake Form
Florida Hospital Spine Center Patient Intake Form Today s Date Last Name First Name Middle Street Address DOB (Address, City, State, Zip Code) First Contact # Please Circle: Home Cell Other Second Contact
New Patient Pain Evaluation
New Patient Pain Evaluation Name: Date: Using the following symbols, mark the areas of the body diagrams which are affected by your pain: \\ = Stabbing * = Electrical X = Aching N = Numbness 0 = Dull S