North Georgia Urology Center, P.C. Urology Patient Questionnaire
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- Augusta Greer
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1 Today s Date North Georgia Urology Center, P.C. Urology Patient Questionnaire Dear Patients: to help the urologist give you better care, please take a moment of valuable time to answer the following questions. Thank you! Name: M F DOB: Primary/ Referring Doctor Date of last physical exam What is the main reason you are being seen today? Have you been seen for this condition before? Yes No Have you ever been seen by a Urologist? Yes No Men: Do you get your PSA checked regularly? Yes No If so, when was it last checked? What was the result (number)? HISTORY OF PRESENT ILLNESS How long have you had this Problem? Where is the problem located? If painful, how would you describe ( cramp, ache, sharp, dull, burn, etc)? On a scale of 1 to 10, most severe being 10, please rate your pain. How long does the problem last? Circle one: seconds minutes hours days all the time Do any other problems or conditions occur at the same time? Yes No If yes, please explain:
2 UROLOGIC HISTORY (circle all that apply): Men: Prostate Cancer Bladder Cancer Kidney Cancer Other Cancer Prostatitis Abnormal PSA Prostate Biopsy Women: Cervical Cancer Bladder Cancer Kidney Cancer Other Cancer Interstitial Cystitis Pain w/ sex Dropped Bladder If you still have periods, when was your last one? Have you ever had the following? (circle if yes) Urine Leakage Drop Bladder Kidney Disease Urinary problems as a child Bowel Leakage Kidney Stone Kidney Failure Mumps after puberty Painful Urination Urinary Infection Dialysis Injury to urinary tract Slow Urination Blood in Urine Urinary Surgery Erection/Sexual Problem Straining to urinate Please list all medications including over the counter drugs (NON Prescription) Medication MG/DOSE Directions/Taken Prescribed ASPIRIN PLAVIX COUMADIN
3 Medical History : Have you ever had any of the following? Circle if yes Heart Attack High Blood Pressure Stomach Ulcers Diabetes Heart Failure Pacemaker Diverticulosis Hepatitis Heart Murmur Blood Clotting Problem Glaucoma Seizures Atrial Fibrillation Gout Tuberculosis Stroke/mini Mitral valve prolapse Radiation Emphysema/COPD Parkinsons Sickle Cell Disease Chemotherapy Thyroid Condition Alzheimer s Anemia Rheumatic Fever GERD Have you ever had any other medical problems? Yes No If yes, please explain DRUG ALLERGIES: Surgeries: List all operations you have had and the year of the surgery: Family History Has anyone in your immediate family (parents, siblings, grandparents) had the following? Prostate Cancer Kidney Stones Bleeding Problems High Blood Pressure Bladder Cancer Kidney Failure Blood Clots Heart Failure Kidney Cancer Blood in Urine Heart Attack Stroke Social History 1.Do you smoke or have you ever smoked? Yes No Packs per day How long (months, years) if quit, how long? 2.Do you drink alcohol? Yes No if so how much? 3.How much caffeine (coffee, tea, soda) do you consume daily? 4. Do you use recreational or IV drugs? (marijuana, cocaine, etc) Yes No 5. Marital Status: Single Partnered Married Separated Divorced Widowed 6. What do you/did you do for a living? 7. Have you traveled outside the U.S. recently? Yes No 8. Have you ever had a blood transfusion? Yes No If so, did you have a negative reaction? Yes No
4 ROS: Circle Y if you are CURRENTLY having any of these symptoms. Circle N if you do not. Constitutional Cardiovascular Fever Y N Chest pain (angina) Y N Chills Y N Irregular Heartbeat Y N Night Sweats Y N Short of breath at rest Y N Weight Loss Y N Short of breath w/ exertion Y N Other Poor Circulation Y N Swelling of legs/ankles Y N Eyes Integumentary Double Vision Y N Boils Y N Cataracts Y N Skin Rash Y N Glaucoma Y N Other Other Allergic/Immunologic Musculoskeletal Hay Fever Y N Back Pain Y N Asthma Y N Arthritis Y N Drug Allergies Y N Weakness Y N Environmental Y N Fibromyalgia Y N Other Other Neurological Ears/Nose/Throat Dizzy Spells Y N Dry Mouth Y N Numbness Y N Sore Throat Y N Tingling Y N Sinus Issues Y N Slipped Disc Y N Hearing Loss Y N Herniated Disc Y N Hearing Issues Y N Headaches Y N Other Other Endocrine Respiratory Hyperthyroid Y N Bronchitis Y N Hypothyroid Y N Wheezing Y N Diabetes Y N Frequent Cough Y N Other Must sleep sitting up Y N Cough Up Blood Y N Gastrointestinal Hematologic/Lymphatic Constipation Y N Bruise Easily Y N Diarrhea Y N Bleeding Problem Y N Vomiting Y N Swollen Glands Y N Bloody Bowels Y N Other Hemorrhoids Y N Psychological Hernias Y N Anxiety Y N Depression Y N ARE YOU SATISFIED WITH YOUR LIFE YES / NO
5 BLADDER SATISFACTION SURVEY PELVIC PAIN and URGENCY/FREQUENCY Name Phone # Doctor Which symptoms best describe you? time) Frequent Urination Day, Night, or Both Sudden or strong urge to urinate Unable to empty the bladder Leaking with Sneezing, Coughing, Excercising Leaking with Urge or No warning (not making it to restroom in Bladder or pelvic pain How long have you had these symptoms? Have you tried medications to help your symptoms? Yes No If yes, check the medications you have tried: Detrol LA Ditropan XL Flomax Cardura Gelnique Oxytrol Patch Enablex VESIcare DDAVP Toviaz Sanctura Elavil Elmiron Other Did these medications help your symptoms? Circle # No Relief Completely Cured If you ve stopped taking your meds explain why: Did not help Side Effects Too Expensive Other Describe Side Effects Behavior Modifications Tried (i.e., caffeine intake, lifestyle changes, bladder training, pelvic floor muscle training) What is your level of frustration with your bladder symptoms? Circle # Not Frustrated Very Frustrated Do you currently have any problems with bowel functions? Fecal Incontinence Constipation Other I am interested in learning more about treatment alternatives to medications: Yes No
6 PATIENT SYMPTOM SCALE Please circle the answer that best describes how you feel for each question Symptom Score Bother Score 1. How many times do you go to the bathroom during the day? 2. a. How many times do you go to the bathroom at night? b. If you get up at night to go to the bathroom does it bother you? 3. Are you currently sexually active? YES NO Never Mildly Moderate Severe 4. a. IF YOU ARE SEXUALLY ACTIVE, do you now or have you ever had pain or symtoms during or after sexual intercourse? b. If you have pain, does it make you avoid sexual intercourse? 5. Do you have pain associated with your bladder or in your pelvis (vagina, lower abdomen, urethra, perineum, testes, or scrotum)? 6. Do you have urgency after going to the bathroom? 7. a. If you have pain, is it usually Mildly Moderate Severe b. Does your pain bother you? 8. a. If you have urgency, is it usually Mildly Moderate Severe b. Does your urgency bother you? SYMPTOM SCORE = (1, 2a, 4a, 5, 6, 7a, 8a) BOTHER SCORE = (2b, 4b, 7b, 8b) TOTAL SCORE (Symptom Score + Bother Score) =
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HeartHealth A Program of the Dalio Institute of Cardiovascular Imaging NEW PATIENT VISIT QUESTIONNAIRE Name: Date of Birth: / / Address: City: State: Zip: Home Phone #: Work Phone #: Cell #: Email: Preferred
GUPTA SPORTS & SPINE CENTER
GUPTA SPORTS & SPINE CENTER NEW PATIENT INFORMATION FORM -ORTHO Please print all information. Thank you for your cooperation. Patient Name: Date of Birth: _ Social Security # Address: City: _ State: Zip
Providence Neurosurgery PATIENT INFORMATION SHEET
Date: Staff only: Weight: Height: BP: Pain Age Patient Name Date of Birth Street Address City State Zip Code Home Phone Work Phone Cell Phone Right handed Left handed Please mark one Referring Physician
DIVISION OF CARDIOLOGY
Name: Date of Birth: / / Home Phone #: Cell Phone #: Work Phone #: Fax #: Address: City: State: Zip: Primary Care Physician: Office Address: Work #: Fax #: Referring Physician (if different): Office Address:
Eastern Shore MediCann Clinic, LLC
Eastern Shore MediCann Clinic, LLC New Patient Medical History and Intake Form Medical Marijuana Certification Name Date of Birth Social Security Number Gender: Male Female Address: Street: City: State
Medical Questionnaire
Medical Questionnaire Date: Day Month Year Please answer these questions as completely as you can. We realize that this form is long, but the information in this form will be extremely valuable to us in
Name Appointment Date. Age Date of Birth Date Completed
Urogynecology Center Name Appointment Date Age Date of Birth Date Completed Reason for Visit Please provide Name, Address, Phone Number, and Fax Number for the following Physicians or Healthcare Providers
Please be sure to check with your insurance company to make sure that Dr. Kohli is covered under your plan.
Dear You are scheduled for an appointment with Dr. Manoj Kohli at Christie Clinic in the Department of Rheumatology on at. Please check in on the first floor. The office is located on the 2 nd floor of
NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW- UP NEUROLOGY QUESTIONNAIRE
Neurology East 48 Medical Park Dr. East Richard G. Diethelm, MD Suite 351 Andrea Sutton, RN, MSN, ANP- BC Birmingham, AL 35235 (205) 836-9366 www.neurologyeast.com NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW-
Patient Interview Form
Page 1 of 5 Orange Coast Memorial Office: 18111 Brookhurst Ave. Suite 5200, Fountain Valley, CA 92708 * Tel: (714) 962-7705 * Fax: (714) 861-4552 www.unitedgi.com Patient Interview Form Patient Information
OhioHealth Orthopedic & Sports Medicine Physicians
Page 1 of 6 OhioHealth Orthopedic & Sports Medicine Physicians 335 Glessner Avenue, Mansfield, Ohio 44903 PATIENT INTAKE ASSESSMENT OFFICE USE ONLY Fax to: OR Control 419-520-2831 For Joint Replacement
Date: Referring Physician Dr. Phone: Primary Care Physician (if different) Dr. Phone:
Kuether Brain and Spine Todd Kuether, MD 19250 SW 65 th Avenue, Suite 260 Tualatin, OR 97062 501 N. Graham, MOB II #515, Portland, OR 97227 (503) 489-8111 Phone (503) 908-6800 fax kuetherbrainandspine.com