ࡱ> e ;*bjbjŘ =-f-fS!PVV87 d!()X?#?#?#?#?#%%%((((((($,6/`(%%%@%%(?#?#f(w'w'w'%^?#8?#(w'%(w'w'w'?#ЪJC&Rw'((0()w'/&/w'/w'w'%%%((w'%%%()%%%%/%%%%%%%%%V a:  New Patient Urologic History Form - Men Patients Name: ______________________________________________________________________________ (Last) (First) (MI) (Date) Age: ___________ DOB: ____________________________ Height ___________ Weight ___________ Referring Dr: _________________________________ Primary Dr:____________________________________ What is the main reason for your visit today? Write in your own words on the lines provided: ____________________________________________________________________________________________ ____________________________________________________________________________________________ When did you first notice the problem? _________________________________________________________ Location of the problem? (if applicable) _________________________________________________________ On a scale of 1-10, with 10 being the most severe, circle the number that best describes the problem. 1 2 3 4 5 6 7 8 9 10 N/A How long does the problem last? __________Is the problem: ( Constant ( Variable ( Seldom Does anything make the problem worse? _____ If yes, what makes it worse? _______________________ Does anything make the problem better? _____ If yes, what makes it better? ________________________ Does the problem interfere with your normal activities? ( Yes ( No What testing have you had to evaluate your urological problem? ( I have had no tests to evaluate this problem ( X-ray ( Ultrasound ( Urodynamic Testing ( CT scan ( Nuclear bone scan ( Other: ___________ ( MRI ( Nuclear renal scan ( Unsure ( IVP ( Urine specimen ( Blood tests ( Cystoscopy Where was the test performed? _________________________________________________________________ Do you leak urine? ( Yes ( No Is your leakage associated with the urge to urinate? ( Yes ( No Is your leakage associated with coughing, laughing, jumping, sneezing, or exercising? ( Yes ( No Do you wear protective pads? ( Yes ( No If so, how many? ___________________________________ Do you have a problem with libido/desire? ( Yes ( No Do you have a problem achieving or maintaining an erection? ( Yes ( No Have you tried any medications for erectile dysfunction? ( Yes ( No If yes, please indicate which medication(s) below: ( Viagra ( Cialis ( Levitra ( Staxyn ( MUSE ( Injection therapy ( Other:_________________ Would you like to discuss erectile function with your doctor today? _______ (Note: an additional appointment may be required if this is not your primary problem) Are there any other urologic issues you would like to discuss with Dr. ____________today? ( Yes ( No (Please explain:) ______________________________________________________________________________ Allergies: Are you allergic to: ( Latex ( Iodine/Betadine ( Penicillin ( Dye/IV Contrast ( Tape/Adhesives ( Sulfa ( Shellfish/Shrimp! ( Anesthetics ( Cipro/Levaquin ( I have no medication allergies Medication allergies: (List all) _____________________________________________________________________________________________ Medications: Do you take any medications? ( Yes ( No Are you currently taking the following blood thinners? ( Aspirin ( 81 mg or ( 325 mg ( Motrin ( Aleve ( Ibuprofen ( Celebrex ( Mobic ( Other: _______________________ ( Coumadin ( Warfarin ( Plavix ( Pradaxa ( Xarelto ( Eliquis ( Heparin ( Lovenox Please list all the medications you take with the dosage and frequency: MedicationDoseHow Often Please list all Vitamins & Supplements such as Vitamin E, Fish oil, Herbal preparation, Garlic, etc:  Past & Present Medical Problems ( Irregular heartbeat( Diverticulosis( Multiple sclerosis( Carotid artery disease( Kidney failure( Myasthenia gravis( Congestive heart failure( Endometriosis( Parkinson disease( High blood pressure( Polycystic kidney disease( Seizures( High cholesterol( Kidney stones( TIA( Heart attack( Vesicoureteral reflux( Anemia( Peripheral vascular disease( Kidney infections/UTI( Sickle cell anemia( Heart valvular disease( Kidney obstruction( Blood clots( Renal artery stenosis( Enlarged prostate/BPH( HIV/AIDS( Heart disease( Prostate infection( Glaucoma( Asthma( STD's( Drug dependency( Bronchitis( Fibromyalgia( Depression( COPD( Gout( Bladder cancer( Cystic fibrosis( Osteoporosis( Breast cancer( Pneumonia( Rheumatoid arthritis( Cervical cancer( Pulmonary embolism( Polio( Colon cancer( Sarcoidosis( Artificial joints( Kidney cancer( Sleep apnea( Lupus( Lung cancer( Tuberculosis( Addison's Disease( Penile cancer( Cirrhosis( Cushing's disease( Prostate cancer( Crohn's disease( Diabetes( Skin cancer( Heartburn/GERD( Hyperthyroidism( Testicular cancer( Hepatitis B( Hypothyroidism( Uterine cancer( Hepatitis C( Alzheimer's( Cancer, Other:( Irritable bowel syndrome( Bipolar  ( Other:_______________( Peptic ulcer disease( Stroke  ____________________( Ulcerative colitis( Dementia _____________________ Surgical History DateSurgeryDateSurgery Family History (please indicate which family member) ( Urinary infections ( Kidney stones ( Prostate cancer ( Bleeding disorders ( Diabetes ( Kidney cancer ( Heart disease ( Bladder cancer ( Other:_____________ Tobacco/ Alcohol History Do you currently smoke? ( Yes ( No How much? ___________________________ Did you smoke in the past? ( Yes ( No How long? ____________ When did you quit? ________________ Do you drink alcohol? ( Yes ( No How many drinks per day? _________________________________ Do you use recreational drugs? ( Yes ( No Substances: __________________________________________ Thank you for taking the time to complete your urological health questionnaire. Welcome to our practice! Prince William Urology Associates, Ltd. REVIEW OF SYSTEMS Name: ______________________________________________________ Date: _____________________ Please ( check only the problems that currently apply to you CONSTITUTIONAL GASTROINTESTINAL INTEGUMENTARY/SKIN ( Fever ( Poor appetite ( Rash ( Chills ( Nausea ( Atypical moles ( Weight gain ( Vomiting ( Itchy skin ( Weight loss ( Diarrhea ( Constipation NEUROLOGIC EYES ( Abdominal pain ( Blood in stool ( Numbness ( Blurred vision ( Heartburn ( Weakness ( Vision loss ( Dizziness GENITOURINARY EARS/ NOSE/ THROAT HEMATOLOGIC/ LYMPHATIC ( Blood in urine ( Hearing loss ( Easy bruising ( Bleeding tendency ( Sinus problems ( Leakage of urine ( Swollen lymph gland ( Difficulty swallowing ( Weak stream ( Sore throat ( Frequency urination ENDOCRINE ( Dental problems ( Urge to void suddenly ( Nose bleeds ( Getting up at night to ( Excessive thirst Urinate ( Hot/cold Intolerance CARDIOVASCULAR ( Problems with erection ( Hormone problem ( Pain with intercourse ( Fatigue ( Chest pain ( Bladder pain ( Palpitations ( Pelvic pain ALLERGY ( Irregular heartbeat ( Burning with urination ( Swelling of feet/ ( Frequent urine infections ( Medication allergy Extremities ( Latex allergy MUSCULOSKELETAL ( Seasonal allergy RESPIRATORY ( Back pain PSYCHIATRIC ( Shortness of breath ( Joint pain ( Chronic cough ( Muscle aches ( Depression ( Coughing up blood ( Anxiety **Healthcare provider only: The above systems have been reviewed by: _______________________ Physicians initials     PRINCE WILLIAM UROLOGY ASSOCIATES, LTD  8525 Rolling Rd, Suite 220 Manassas, VA 20110-3648 Phone: (703) 393-0700; Fax: 703-393-0661 Ali M Sajadi, MD - Andrew K Chung, MD - Amy K Moreno, MD - Anshu Guleria, MD "()* X Y d i j o u ~   ! 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