Urology CHIEF COMPLAINT ALLERGIES. What is the main reason for your visit today? Allergen Yes No Reaction

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Transcription:

Urlgy Kari White, NP Phne: 646-962-9600 Name: Date f Birth: Date: CHIEF COMPLAINT What is the main reasn fr yur visit tday? ALLERGIES Are yu allergic t any f the fllwing? Please check YES r NO fr each. Check here if yu have NO knwn allergies. Allergen Yes N Reactin Penicillin Sulfa Latex IV Cntrast Dye Cipr/Levaquin Macrbid/Nitrfurantin Others (please list) 1

Urlgy MEDICATIONS Please list the name, dsage and frequency f all medicatins yu are taking (include regularly used ver-the-cunter medicatins/supplements). IF YOU HAVE A MEDICAL LIST WITH YOU, PLEASE SUBMIT IT WITH THIS FORM. Check here if yu are currently taking NO medicatins. Medicatin Dse Hw Often? SURGICAL HISTORY Have yu ever had any f the fllwing surgeries r prcedures? Please check YES r NO fr each. Check here if yu have had NO surgeries r prcedures. Urlgic Surgeries Yes N Date Kidney surgery Bladder r Incntinence surgery Males Only Scrtal/Testicle surgery Penis surgery Gyneclgical Surgeries (Females nly) Yes N Date Hysterectmy C-Sectin (Number f deliveries: ) 2

Abdminal Surgeries Yes N Date Appendix remval Gallbladder remval (chlecystectmy) Hernia surgery Grin (inguinal)? Side? Navel (umbilical)? Remval f bwel Bag fr drainage f stl (stmy)? Aneurysm repair Brain, Head r Neck Surgeries Yes N Date Cartid surgery Chest Surgeries Yes N Date Heart bypass Artificial heart valve Jint r Bne Surgeries Yes N Date Artificial jint/replacement? Which ne? Orthpedic prcedures? Other Surgeries (Please List) Date 3

PAST MEDICAL HISTORY Have yu ever been treated fr any f the fllwing medical prblems? Please check YES r NO fr each. Cnditin Yes N Adrenal Prblems Asthma/Emphysema Bld Clts/Bleeding Prblems/Deep Vein Thrmbsis/Pulmnary Emblus Cancers (please list): Cataracts Cngestive Heart Failure Diabetes Gastrintestinal Bleeding Glaucma Gut Heart Attack/Strke Hepatitis High Bld Pressure HIV/AIDS Irregular Heart Beat Kidney Failure Kidney Stnes Mumps Sleep Apnea Thyrid Disease Tuberculsis Urinary Infectins Females Only: Number f Pregnancies: Number f Miscarriages: Other (please list): FAMILY HISTORY D yu have any clse relatives with any f the fllwing cnditins r d any f the fllwing cnditins run in yur family? Please check YES r NO fr each. Cnditin Yes N Prstate Cancer Bladder Cancer Kidney Cancer Kidney Stnes Diabetes High Bld Pressure Other Cancers Other (please list): 4

SOCIAL HISTORY Please check r fill in the apprpriate answer fr each questin. Questin Answer What is yur marital status? Married Single Divrced Separated D yu smke? Yes, Daily Yes, Nt Daily Nt Anymre Never Smked Cigar Cigarettes If yes, what d yu smke? Vaprizer Marijuana Hw lng have yu smked? When did yu quit? Hw many packs per day? D yu use any f the fllwing: Chewing tbacc/snuff Edible marijuana Illegal substances (drugs) D yu drink alchl? Yes N Nt anymre Hw much d yu drink per week? What d yu drink? Beer Wine Liqur When did yu quit? Hw many caffeinated beverages d yu have per day? Have yu ever had a bld transfusin? What is yur primary language? English Japanese German French Chinese Russian Spanish Italian Prtuguese Other: What is yur race? White Other: Hispanic/Latin Asian American Indian/Alaskan Native Native Hawaiian /Pacific Islander Black/African American What d yu d fr a living (what is yur ccupatin)? 5

REVIEW OF SYSTEMS Check here if yu have n prblems in any areas Cnstitutinal Yes N Fever Chills Weight Lss Eyes Yes N Blurry Visin Duble Visin Cataracts Ears, Nse, Muth, Thrat Yes N Hearing Lss Nasal Stuffiness Sre Thrat Cardivascular Yes N Chest Pain Swllen Ankles Irregular Heart Beat Pacemaker Internal Defibrillatr Crnary Stents Angicaths Respiratry Yes N Shrtness f Breath Wheezing Chrnic Cugh Gastrintestinal Yes N Abdminal Pain Nausea/Vmiting Cnstipatin Diarrhea Musculskeletal Yes N Chrnic Back Pain Chrnic Neck Pain Sre Muscles Integumentary, Skin Yes N Rash Persistent Itchiness Skin Cancer Histry Neurlgical Yes N Numbness Dizziness Tingling Hematlgical, Lymphatic Yes N Swllen Glands Abnrmal Bleeding Bruise Easily Endcrine Yes N Chrnic Fatigue Chrnically t Ht/Cld Excessive Thirst Respiratry Yes N Shrtness f Breath Wheezing Chrnic Cugh Sexual Functin Yes N Sexually Active Decreased Erectins Ejaculatin Issues Decreased Libid Other: I have read and answered all f the questins in their entirety and the infrmatin is accurate and true t the best f my knwledge. Signature Date 6 6

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