SEX: M F MARITAL STATUS: S.S#: ADDRESS: WHICH NUMBER WOULD YOU LIKE US TO USE AS YOUR PRIMARY CONTACT: HOME CELL WORK PHARMACY NAME: PHONE:

Size: px

Start display at page:

Download "SEX: M F MARITAL STATUS: S.S#: ADDRESS: WHICH NUMBER WOULD YOU LIKE US TO USE AS YOUR PRIMARY CONTACT: HOME CELL WORK PHARMACY NAME: PHONE:"

Lucas Simon
5 years ago
Views:

1 Comprehensive Urologic Specialists: 1203 Langhorne-Newtown Rd, St Clare Bldg. Ste. 334 Langhorne, PA PATIENT INFORMATION FORM PATIENT NAME: DOB: STREET APT#: CITY STATE ZIP SEX: M F MARITAL STATUS: S.S#: ADDRESS: HOME PHONE #: CELL PHONE #: WHICH NUMBER WOULD YOU LIKE US TO USE AS YOUR PRIMARY CONTACT: HOME CELL WORK OCCUPATION: WORK PHONE #: EMPLOYER: RACE: AMERICAN INDIAN OR ALASKA NATIVE ETHNICITY: HISPANIC ASIAN AFRICAN AMERICAN OR BLACK NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER WHITE DECLINE TO ANSWER SPOUSE/GUARDIAN NAME: NAME OF CONTACT PERSON OTHER THAN SPOUSE: NON-HISPANIC DECLINE TO ANSWER LANGUAGE: RELATIONSHIP: PHONE #: REFERRED BY: FAMILY/PRIMARY CARE PHYSICIAN (PCP): PHARMACY NAME: PHONE: PHARMACY ADDRESS: PRIMARY INSURANCE: POLICY HOLDER S NAME: DOB: PATIENT S RELATIONSHIP TO POLICY HOLDER (circle one): SELF SPOUSE CHILD OTHER SECONDARY INSURANCE: POLICY HOLDER S NAME: DOB: PATIENT S RELATIONSHIP TO POLICY HOLDER (circle one): SELF SPOUSE CHILD OTHER CONSENT: I request and authorize Health Care Services by my physician and his/her designees as may deem advisable. This may include routine diagnostic, radiology and laboratory procedures and medication administration. A chaperone will be available for any exam by request, and may be refused at my discretion.yes NO MEDICAL BENEFITS PAYMENT AUTHORIZATION: I authorize payment of medical benefits to Langhorne Physician Services for the amount due on any pending claim for services rendered. YES NO SIGNATURE: DATE: Updated 4/7/2015

2 HIPAA Patient Acknowledgment Form Our Notice of Privacy Practices (NPP) provides information about how COMPREHENSIVE UROLOGIC SPECIALISTS may use and disclose protected health information (PHI) about you. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act (HIPAA). The NPP contains a Patient Rights section describing your rights under the law. Please review the Notice of Privacy Practices thoroughly before signing this acknowledgement form. In the event that terms of the Notice change, a revised copy will be made available to you. By signing this form, you acknowledge that our Practice may use and disclose PHI about you for treatment, payment and healthcare operations. You have the right to request that we restrict how PHI about you is used or disclosed for treatment, payment or healthcare operations. I give permission for COMPREHENSIVE UROLOGIC SPECIALISTS to: Leave a message regarding an appointment at (phone number) Leave a message regarding test results (phone number) Share medical information with: (1) Name Relationship Phone (2) Name Relationship Phone I assume responsibility to inform the practice of any changes in the above information. Print Patient s Name Patient s Date of Birth Signature Date Relationship to Patient Today s Date I have received the Notice of Privacy Practices Signature Relationship to patient Date

3 PATIENT NAME: AGE: Today s Date: REASON FOR VISIT: REQUESTING PHYSICIAN: PERSONAL HISTORY: Allergy History: Medication allergies: Yes No If Yes, list medication and reaction: Topical iodine Allergy: Yes No Latex Allergy: Yes No Allergic to IV contrast/x-ray dye (used in imaging studies)? Yes No Other allergies: Family History: Relation Living Deceased Age Cause of Death Mother Father Siblings Siblings Family urologic history. Past Medical History: Do you have? Poor vision Poor hearing Language barrier Religious/cultural barrier Do you have any metal implants (such as plates, screws, clips, pacemaker, joints etc.)? Yes No Do you have mitral valve prolapse or valvular disease? Yes No Do you require premedication with antibiotics before a dental procedure? Yes No Have you ever had a blood transfusion? Yes No Have you ever had Hepatitis? Yes No If yes, which type of Hepatitis? A B C Other Have you ever had a blood test for HIV (AIDS)? Yes No If yes, results were positive or negative Hospitalization / Surgeries Year Hospital Surgeon Reason Social History: Have you ever smoked? Yes No Amount per day: How long have you or did you smoke? When did you quit smoking? Have you ever injected illegal drugs? Yes No Do you drink alcohol? Yes No Amount per day: Your Occupation: Marital Status: Single Married Divorced Widowed Do you have children? Yes No What are their ages: Your Hobbies:

4 Urologic History: Do you now or have you had any of the following in the past? Please explain any Yes answers in space provided Y N Y N Y N Blood In Urine Kidney Stones MALES ONLY Frequent Urinary Painful Urination/ Burning Infections (UTI) Blood in semen Urinary Frequency Incontinence Trouble with erections How often? times/day Waking to urinate? How often? times/night Leak urine when sneezing How many pads/day? Aware of wetting? Prior treatment for erection dysfunction Elevated PSA Problems with ejaculation Urinary Urgency Venereal Disease Decrease desire for sex Urine Retention Urethral Discharge Testicular Pain Intermittent stream Vaginal Discharge Ejaculatory Pain Feeling not completely emptying Kidney Disease Prostate infections Long wait or hesitation starting urinating Straining or pushing to urinate/ Difficult Voiding/ Slow Stream Flank / Kidney Pain/ Abdominal Pain Other History: Do you now or have you had any of the following in the past? Enlarged Prostate/ BPH Other: Please explain any Yes answers in space provided Y N Y N Y N Atrial fibrillation Ulcerative Colitis Arthritis Heart Attack Diverticulosis Seizures Abnormal Heart Beat Diverticulitis Stroke Coronary Artery Disease Crohn s Parkinson s Disease High Cholesterol Irritable Bowel Anemia High Blood Pressure Liver Disease (non alco) Migraines Heart Murmur Diabetes GYNECOLOGIC (Females) Phlebitis Thyroid Disease Number of Pregnancies: Heart Failure Gout Last Menstrual Period: Rheumatic Heart Disease Asthma Last GYN evaluation: Cancer of Bronchitis Endometriosis Glaucoma Emphysema Ectopic pregnancies Cataract Tuberculosis Abortions Acid reflux Pneumonia Other GYN Concerns: Peptic Ulcers Hay Fever

5 Medications (Please include all drugs, i.e. Over-the-Counter, Non-Prescription or Herbal Drugs. Also, include any blood thinners such as Coumadin, Ticlid, Persantine, Plavix, or Aspirin): Medication Dosage How Often? Medication Dosage How Often? CURRENT MEDICAL CONDITIONS (Review of Systems): GENERAL Y N Y N Y N Neck Pain or RESPIRATORY problems Weight Loss Chronic Cough NEUROLOGICAL Chills Shortness of Breath Numbness / Tingling Fatigue Spitting Up Blood Dizziness Fever Wheezing Headaches SKIN CARDIOVASCULAR Tremors Persistent Itch Chest Pain Light Headed Skin Rash Swelling of Feet or ankles PSYCHIATRIC Boils Varicose Veins Anxiety Breast Lumps GASTROINTESTINAL Depression HEAD /EYES /EARS Diarrhea / chronic Insomnia /NOSE/THROAT Blurred Vision Abdominal Pain Memory Loss Double Vision Constipation ENDOCRINE Eye Pain Heartburn / Indigestion Excessive Thirst Hearing Loss Nausea / Vomiting Too Hot / Cold Ear Infection Rectal Bleeding Hormone Problem Nose Bleeds Loss of Appetite HEMATOLOGIC Sinus Problems Other GI Concerns Easy Bleeding Sore Throat MUSCULOSKELETAL Easy Bruising NECK Back Pain Swollen Glands Neck Pain Joint Pain Blood Clotting Problem Swollen Glands Muscle Weakness Please explain all Y (Yes) answers (use back of page if necessary): Details of ROS (To be completed by Physician): Physician Signature: Date:

6 What is your approx Height? Ft. Inches Approx Weight? Lbs. Genito-Urinary History Not at All Less than 1 time in 5 Less than half the time About half the time More than half the time Almost Always Incomplete Emptying Over the past few months how often have you had a sensation of not emptying your bladder completely after you finished urinating? Intermittency Over the past month how often have you found you stopped and started again several times during urinating? Urgency Over the past month, how often have you found it difficult to postpone urination? Frequency Over the past month, how often have you had to urinate again less than two hours after you finished urinating? 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? Nocturia How many times do you typically get up at night to urinate, from the time you go to bed until the time you get up in the morning? Total Score If you were to spend the rest of your life with your voiding condition just the way it is now, how would you feel about that? (Circle your answer) Delighted -- Pleased -- Mostly Satisfied -- Mixed -- Most Dissatisfied Unhappy -- Terrible Do you have leakage of urine? Yes No How many pads do you use each day (if applicable)? Pads per day Do you have: A history of bladder, kidney or prostate infections? Yes No A history of blood in the urine? Yes No A history of kidney stones? Yes No Difficulty or dissatisfaction with sexual function? Yes No A history of HIV/Venereal Disease? Yes No

Adult Demographics Form

Adult Demographics Form Patient s Name: Preferred Name: Age: Patient s Social Security Number: Date of Birth: Sex: M / F Home Address: Apt: City: State: Zip: Cell phone #: Home Phone #: Work phone #: Email: