Hackensack(University(Medical(Group( (Urology( 360(Essex(Street,(Suite(403(((Ι(((Hackensack,(NJ(07601(((Ι(((551F996F8090((((Ι((((

Transcription

1 IHORS.SAWCZUK,M.D.,F.A.C.S. Professor & Chairman Chief, Urologic Oncology John Theurer Cancer Center Executive VP & Chief Medical Officer RAVIMUNVER,M.D.,F.A.C.S. Associate Professor & Vice Chairman Chief, Minimally Invasive & Robotic Urologic Surgery Urologic Oncology & Kidney Stones KEVINR.BASRALIAN,M.D.,F.A.C.S. Attending MICHAELDEGEN,M.D. Clinical Assistant DEBRAFROMER,M.D. Assistant Professor Chief, Center for Bladder, Prostate & Pelvic Floor Health MICHELLEKIM,M.D. Assistant Professor Chief, Prostatic Disorders and Pelvic Tumors HARRYP.KOO,M.D.,F.A.A.P.,F.A.C.S. Professor Chief, Pediatric Urology DAVIDSHIN,M.D. Assistant Professor Chief, Center for Sexual Health & Fertility Men s Health RICHARDWATSON,M.D.,F.A.C.S. Professor Chief, Ambulatory Urology ALANN.LEIPSNER,MPH,MBA,FACHE Administrative Director Urology Academic Affairs Medical Library DearPatient, ThankyouforchoosingHackensackUniversityMedicalGroup Urology.Welookforwardto meetingyouandprovidingyouwiththehighestqualityurologicalcare.inadditiontoour physicians,nursesandclinicalassistants,whowilllookafteryourmedicalneeds;our administrativestaffisheretohelpyouwithscheduling,billing,andothernonfclinicalissues. Pleasetakeafewminutes,priortoyourfirstvisit,tocompleteandreviewthefollowing informationrelatedtoourpractice.doingso,willenableustoserveyouasefficientlyaspossible. Office&hours&by&appointment& To&schedule&an&appointment&please&call&)&996<89& & Includedinthispacketforyourreviewandcompletionarethefollowing: RegistrationForm NewPatientInformationForm Questionnaires) Directions&Map Inaddition,weaskthatyoubringthefollowingtoyourappointment: CompletedForms DriverslicenseorlegalformofpictureID InsuranceCard InsurancecoFpay Listofmedicationsandallergies Anyandallradiologyfilms&reports Pleaseprovideanyradiologyimagese.g.XFRay, MRI,CatScan,and/orUltrasound),orstudyresultsrelatingtoyourvisit Whileunderthecareofourphysiciansifyouneedtorenewaprescription,pleasecallyour pharmacyorfillouttheonlineprescriptionrenewalform,foundonourwebsite,urologynj.com. PleasenoteHackensackUMG UrologyhasanoFshowpolicy.Kindlycancelorrescheduleyour appointmentatleasthoursinadvance.ifapatientisscheduledforanappointmentanddoes notcancelorreschedule,aletterwillbesenttothepatientchargingthem$. ForbillingquestionscontactyourbillingrepresentativewithinthedepartmentatF996F866. ForallbillinginquiriesanddetailsonyourstatementpleasecontactHackensackUMG sbilling Officeat866)7F98. OurgoalistoprovideyouwithexceptionalserviceandstateoftheartpatientFcenteredmedical careinanenvironmentthatissensitivetoyourneeds.pleaseletusknowhowwearedoingor howwemayimproveourserviceanddonothesitatetocallusifyouhaveanyquestions. ThankyouagainforchoosingHackensackUMG Urologyandwelookforwardtomeetingyou. HackensackUniversityMedicalGroup Urology 6EssexStreet,SuiteΙHackensack,NJ76ΙF996F89Ι

2 PatientInformation Date:& & SSN#:& & Last&Name:& & First&Name:& & Date&of&Birth:& & Gender:& &Male& &&&&&&&Female& Address:& & City:& & State:& & Zip:& & Special&Living&Arrangements: & &None&&&&&&& &Assisted&Living&&&&& &Nursing&Home& Home&Phone:& & Cell&Phone:& & EFmail&Address:& & Race:& American&Indian/Alaska&Native& Asian& African&American/Black& & Native&Hawaiian/Pacific&Islander& White/Caucasian& & Ethnicity:& Central/South&American& Cuban& Mexican& Puerto&Rican& & Other&Hispanic/Latino& NonFHispanic/Latino& Preferred&Language:& & Marital&Status: & Employment: &Employed&& &Medical&Disability& &SelfFEmployed&& &Retired&& &Unemployed& Employer:& &Employer&Address:& & Emergency&Contact:& &Relation:& Address:& &Phone&#& Pharmacy&Name:& &Phone&#& & How&did&you&hear&about&us:& & PrimaryPhysicianInformation NAME: & ADDRESS: & PHONE#: & & & &&&&&&&&&& & Patient s&signature& & & & & & Date&

3 InsuranceInformation PrimaryInsurance Name&of&Policy&Holder/Guarantor:& &DOB:& & Relationship&to&Patient:& &SSN#:& & Policy&Holder/Guarantor s&address:& & Status:&Employed&&&&Medical&Disability&&&&&&&&&&&SelfFEmployed&&&&&&&&&&&&&Retired&&&&&&&&&&&& Unemployed& Employer:& &Employer&Address:& & Insurance&Company:& & Insured s&policy/&id&#:& &Group&#:& & Insurance&Co.&Address:& &Phone&#:& & &&&&&&&&&&&&Name&of&Lab&Determined&by&Insurance:& & FFFFFFFFFFFFFF&DO&YOU&HAVE&ANY&ADDITIONAL&INSURANCE?&&&Yes&&&No&FFFFFFFFFFFFFF& SecondaryInsurance IF&YES,&PLEASE&COMPLETE&THE&FOLLOWING:& Name&of&Policy&Holder/Guarantor:& &DOB:& & Relationship&to&Patient:& &SSN#:& & Policy&Holder/Guarantor s&address:& & Status: &Employed&& &Medical&Disability& &SelfFEmployed&& &Retired&& &Unemployed& Employer:& &Employer&Address:& & Insurance&Company&Address:& & Insured s&policy/&id&#:& &Group&#:& & Insurance&Co.&Address:& &Phone&#:& & & PLEASE&PROVIDE&INSURANCE&CARDS&AND&PICTURE&ID&TO&FRONT&DESK& MAKE&CHECKS&PAYABLE&TO& HUMG &

4 International Prostate Symptom Score IPSS) Name: Date: Incomplete emptying Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating? Frequency Over the past month, how often have you had to urinate again less than two hours after you finished urinating? Intermittency Over the past month, how often have you found you stopped and started again several times when you urinated? Urgency Over the last month, how difficult have you found it to postpone urination? Weak stream Over the past month, how often have you had a weak urinary stream? Straining Over the past month, how often have you had to push or strain to begin urination? Not at all Less than time in Less than half the About half the time More than half the Almost None time times times times times or more Your score Your score Nocturia Over the past month, many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning? Total IPSS score Quality of life due to urinary symptoms Delighted Pleased Mostly satisfied Mixed about equally satisfied and Mostly If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that? 6 Total score: -7 Mildly symptomatic; 8-9 moderately symptomatic; - severely symptomatic. Unhappy Terrible

5 International Index of Erectile Function IIEF) Questionnaire Please circle the appropriate numbers below. How often were you able to get an erection during sexual activity? no sexual activity never. When you had erections with sexual stimulation, how often were your erections hard enough for penetration?. When you attempted sexual, how often were you able to penetrate enter) your partner?. During sexual, how often were you able to maintain your erection after you had penetrated entered) your partner?. During sexual, how difficult was it to maintain your erection to completion of? 6. How many times have you attempted sexual? 7. When you attempted sexual, how often was it satisfactory? 8. How much have you enjoyed sexual? 9. When you had sexual stimulation or, how often did you ejaculate?. When you had sexual stimulation or, how often did you have the feeling of orgasm or climax?. How often have you felt sexual desire?. How would you rate your level of sexual desire?. How satisfied have you been with your overall sex life?. How satisfied have you been with your sexual relationship with your partner?. How do you rate your confidence that you could get and keep an erection? no sexual activity did not attempt did not attempt did not attempt no attempts did not attempt no no sexual stimulation/ no sexual stimulation/ never never never extremely difficult one to two attempts never no enjoyment never never never very low/ none at all very very very low very difficult three to four attempts not very enjoyable low moderately moderately low difficult five to six attempts fairly enjoyable moderate about equally satisfied and about equally satisfied and moderate slightly difficult seven to ten attempts highly enjoyable high moderately satisfied moderately satisfied high not difficult eleven + attempts very highly enjoyable very high very satisfied very satisfied very high Patient Name Today s Date SHIM:,,, 7, :

6

7

8

9 Alfred Sanzari Medical Arts Building 6 Essex Street, Suite Hackensack, NJ Directions from Paterson Area and West Follow Route 8 East, staying in local lanes to Exit 6B for Rochelle Park and Paramus. Exit ramp sign says Exit 6). Turn left off exit ramp and turn right at light onto Essex Street. Follow Hospital signs. At fifth light, turn left onto Summit Avenue. Turn immediate right onto Thompson Street to access our underground parking garage. Take the elevators to the th floor. From George Washington Bridge East Follow Route 8 West, staying in local lanes, to Exit 6B. Turn right at light onto Polifly Road. Travel north on Polifly Road. At second light, turn left onto Essex Street. At first light, turn right onto Prospect Avenue. Make an immediate left onto Thompson Street to access our underground parking garage. Take the elevators to the th floor. From Southern New Jersey via the New Jersey Turnpike Follow Route 9-N.J. Turnpike North to the junction of Route 8. Take 8 West and stay in lanes for "Local Exits" to exit 6B for Hasbrouck Heights and Newark. Turn right at light onto Polifly Road. Travel north on Polifly Road. At second light, turn left onto Essex Street. At first light, turn right onto Prospect Avenue. Make an immediate left onto Thompson Street to access our underground parking garage. Take the elevators to the th floor. From Northern New Jersey on Route 7 Follow Route 7 South to Essex Street exit. Turn left onto Essex Street. At fourth light, turn left onto Summit Avenue. Turn immediate right onto Thompson Street to access our underground parking garage. Take the elevators to the th floor. From Southern New Jersey on Route 7 Follow Route 7 North to Polifly Road turnoff. Go under the Route 8 overpass and turn left at the second light onto Essex Street. At first light, turn right onto Prospect Avenue. Make an immediate left onto Thompson Street to access our underground parking garage. Take the elevators to the th floor. From the Lincoln Tunnel Take Route West to Route 7 North to Essex Street exit. Turn right onto Essex Street. At second light, turn left onto Summit Avenue. Turn immediate right onto Thompson Street to access our underground parking garage. Take the elevators to the th floor. From the Garden State Parkway From the Garden State Parkway, either north or south, take Route 8 East. Follow directions above for Paterson Area and West. Revised //

10 Hackensack University Medical Center Campus Map HBF #787 Rev. /