Annual Exam Review Name Medications: Medication Strength (mg) Directions ( how many pills and how many times a day) Overall health: Good Fair Poor Men : When was the last time you had: Prostate exam Prostate cancer blood test (PSA) Colonoscopy Eye exam Women: When was the last time you had: PAP smear Mammogram Colonoscopy Bone Density Eye exam All patients : Do you exercise? Yes No If yes, how much? minutes times/week Type of exercise Do you smoke? Yes No If yes, how much? Packs/day Do you drink alcohol? Yes No If yes, how much? drinks/week Do you use any drugs? Yes No What type? Are you sexually active? Yes No How many partners in the past year? Partners are female male Condom use always sometimes never Do you have a living will or health care proxy? Yes No If you don t have one and would like one please visit our website: Doctormelgar.com where you can download them for free. Have your Mother, Father, or Siblings developed Heart Disease in the past year? If yes, who did? Have your Mother, Father, or Siblings developed Cancer in the past year? If yes, who and what type of cancer?
Circle any physical complaints that you have. Fever Feeling poorly Recent wt gain Chills Feeling tired Recent wt loss Earache Nosebleeds Sore throat Loss of hearing Nasal Discharge Hoarseness Chest pain Calf pain when walking Rapid heart beat Palpitations Swelling in legs Shortness of breath at rest Wheezing Cough Short of breath with exertion Abdominal pain Constipation Heartburn Vomiting Diarrhea Black stools Pain on urination Trouble starting urination Lesion on genitals Loss of urinary control Waking from sleep to urinate Erectile dysfunction Skin lesions Itching Dry skin Rash Joint pains Muscle pains Change in a mole Joint swelling Joint stiffness Confusion Dizziness Weakness in arms or legs Seizures Fainting Trouble walking
North Shore Medical Associates, p.c. Internal Medicine 107 Northern Blvd., Suite 206 Great Neck, NY 11021 www. doctormelgar. com Telephone (516) 829-2016 Michael J. Melgar, MD Fax (516) 829-2019 ANNUAL WAIVER Date Dr. Melgar has advised me that the procedure(s) performed today may not be fully reimbursed by my insurance as they may not be considered medically necessary according to the terms and conditions of my policy. I have been advised that the annual consists of an evaluation, EKG, bloodwork, urinalysis, and any other tests the doctor feels are necessary for screening purposes. Although, my insurance may reduce/deny the procedure(s), I have advised the doctor to proceed with the services and will assume full responsibility for the payment. Patient Name: Signature: Witness:
Please read and complete the items below All patients please answer these questions. Yes No I would like to have testing for sexually transmitted diseases during this visit Yes No I would like to review techniques for smoking cessation during this visit For Men 50 to 75 years old: I have read the attached PSA information sheet and have decided to either have or not have the PSA test done as directed below. I understand the risks and benefits of this test and have been given adequate opportunity to have my questions answered. I have decided to have the PSA blood test I have decided NOT to have the PSA blood test First Name: Last Name: Signature: Date:
North Shore Medical Associates NEWSLETTER PSA Prostate Screening Should you have the test? Although the debate surrounding the PSA test may seem new, the test has been surrounded by controversy since it first became available in 1986. Most recently the PSA has been in the news because the United States Preventative Services Task Force (USPSTF) has recommended that the PSA no longer be a routine part of mens physical exams. This has lead to a good deal of confusion for patients. What is the PSA? PSA (Prostate Specific Antigen) is a blood test. PSA is a protein produced in normal prostate tissue. Researchers noticed that some prostate cancer cells made higher levels of PSA than most normal prostate cells and concluded that this might be an easy noninvasive way to screen for prostate cancer. Since that time it has been a common part of the blood work done during physical exams for most men between the ages of 40 and 75. Why is there controversy about the test? The problem with the test is that sometimes normal prostate tissue can produce high levels of PSA and cancerous prostate tissue can produce normal levels of PSA. These issues can cause both false positive and false negative results. Studies have been done looking at whether the PSA test results in reduced death rates or longer lives for prostate cancer patients. These studies seem to indicate there is no benefit. This may not seem to make sense but the truth is that early detection does not always result in better outcomes. Many prostate cancers are relatively harmless and may never have resulted in death. Other may be so aggressive that even in its earliest stages treatment has little benefit. There may be some types where treatment will help but there is no way currently to separate the various types. Is there a down side to doing the test? A positive PSA often results in the need for a painful biopsy. If the biopsy is positive then radiation or surgery is often recommended. These treatments all have potential side effects. Impotence is a very common complication, but obviously there can be a good deal of discomfort and in rare cases even more serious complications are possible. So what should patients do? Its important to weigh the risks of doing the test (unnecessary treatments) against the benefits, which are debatable at this point, in order to make a decision. The USPSTF is saying that PSA s should not be done routinely on men as part of their physical exam. The patient should discuss this with their physician and request the test only once they fully understand the pros and cons