Patient Info Form - Urologic Associates

Patient Info

The information you submit via this form is not saved in any way. It is used solely to generate a PDF document for your conveinance to print and bring with you to your appointment. You are not obligated to enter any information on this form but you may be asked to fill it in when you arrive for your appointment.

If you prefer, you may download the blank form, print it, and fill it in by hand.

Adobe Acrobat Reader is required to view this form.

Patient Information

Name

Address

City State Zip

Home Phone Work Phone

Date of Birth -- Gender

Social Security Number

Occupation
(If retired, former occupation)

Marital Status Spouse's Name

Power of Attorney

Parent/Legal Guardian

Referring Physician Phone

Address

Family Physician Phone

Address

Insurance Information

Primary Coverage

Select Type

Insurance ID #

Insurance Group #

Insurance Company

Employer Name

Address

Policy Holder

Same as Patient Information

Name

Address

Date of Birth --

Relationship to Patient

Secondary Coverage

Select Type

Insurance ID #

Insurance Group #

Insurance Company

Employer Name

Address

Policy Holder

Same as Patient Information

Name

Address

Date of Birth --

Relationship to Patient

Release of Information Directives

May we communicate information concerning your:

Appointments

On your answering machine?		Phone
On your voice mail?		Phone
By mail?		Address
To another person? (eg. Family Member, Doctor, etc.)		Name(s)

Medical Information

On your answering machine?		Phone
On your voice mail?		Phone
By mail?		Address
To another person? (eg. Family Member, Doctor, etc.)		Name(s)

I specifically do not want information released to:

Patient Medical Hostiry

1. What is the reason for your visit?

2. How long have you had this condition?

3. What treatment have you had for this?

Medical History

1. What medical conditions do you have now?

2. What medical conditions have you had in the past?

3. Have you ever had surgery or been hospitalized?

If yes, please list below.

Surgery & Hospitalizations	Facility & Physician Name	Date
		--
		--
		--
		--
		--
		--

Please list or provide a list of your current medications.

Name of Medication	Dose	Times Per Day

4. List medication allergies

5. Do you smoke? How much? (packs per day)

Have you smoked in the past?

How long, the year you quit?

6. Do you use alcohol?

If yes, how much in an average week?

7. Do you drink caffeinated beverages?

Family History

Has a member of your family (not related by marriage) ever had any of the following diseases? If yes, state relation to you.

1. Kidney Stone
2. Prostate or other Urologic Cancer
3. Chronic Kidney or Urinary Tract Problems
4. Colon or Rectal Cancer
5. Other Family Diseases

Female Medical History

Obstetrical History

Number of pregnancies

Living children

Gynecological History

Date of last menstrual period --

Are you sexually active at the present time?

Do you have a cystocele/rectocele (dropped bladder/organ)?

Are you presently taking (or have in the past) estrogen hormone replacement?

Review of Systems

Do you now or have you had any problems related to the following systems?
Please explain any Yes answers in the space provided.

Constitutional Symptoms

Fever

Chills

Headache

Other/Explanation

Eyes

Blurred vision

Double vision

Pain

Other/Explanation

Allergic/Immunologic

Hay Fever

Drug Allergies

Other/Explanation

Neurological

Tremors

Dizzy Spells

Numbness/tingling

Other/Explanation

Endocrine

Excessive thirst

Too hot/cold

Tired/sluggish

Other/Explanation

Gastrointestinal

Abdominal pain

Nausia/vomiting

Indigestion/heartburn

Other/Explanation

Cardiovascular

Chest pain

Varicose veins

High blood pressure

Other/Explanation

Integumentary

Skin rash

Boils

Persistent itch

Other/Explanation

Musculoskeletal

Joint pain

Neck pain

Back pain

Other/Explanation

Ear/Nose/Throat/Mouth

Ear infection

Sore throat

Sinus problems

Other/Explanation

Genitourinary

Urine retention

Painful urination

Urinary frequency

Other/Explanation

Respiratory

Wheezing

Frequent cough

Shortness of breath

Other/Explanation

Hematologic/Lymphatic

Swollen glands

Blood clotting problems

Other/Explanation

Psychologic

Are you generally satisfied with your life?

Do you feel severely depressed?

Have you considered suicide?

Other/Explanation

Please be sure to read the form carefully once you print it and sign where necessary. You may keep pages 3 (financial policy/procedure), 6, and 7 (privacy notice) for your records.

Urologic Associates of Allentown

Patient Info

Patient Information

Insurance Information

Primary Coverage

Policy Holder

Secondary Coverage

Policy Holder

Release of Information Directives

Appointments

Medical Information

Patient Medical Hostiry

Medical History

Family History

Female Medical History

Obstetrical History

Gynecological History

Review of Systems

Constitutional Symptoms

Eyes

Allergic/Immunologic

Neurological

Endocrine

Gastrointestinal

Cardiovascular

Integumentary

Musculoskeletal

Ear/Nose/Throat/Mouth

Genitourinary

Respiratory

Hematologic/Lymphatic

Psychologic