UT Erlanger Urology
Erlanger East Campus Erlanger Main Campus Parkridge East Campus
1755 Gunbarrel Rd, Ste 209 979 E. 3rd St, Ste C-925 961 Spring Creek Rd, Ste 202
Chattanooga, TN 37421 Chattanooga, TN 37403 Chattanooga, TN 37412
PATIENT INFORMATIONPatient’s First Name: Middle: Last: / q Mr.
q Mrs.
q Dr. / q Miss
q Ms. / Marital Status (circle one):
Single / Mar / Div / Sep / Wid
Street Address: / City: / State: / ZIP Code:
Social Security Number: / Home phone number:
( ) / Cell phone number:
( )
Birth date:
/ / / Age: / Sex:
q M q F / Pharmacy Name: / Street your pharmacy is on:
Occupation: / Employer: / Employer phone number:
( )
Primary Care Physician: / Employer Address:
Do you have power of attorney? q Yes q No If yes, person’s name: Phone Number:
Do you have a living will? q Yes qNo
Referred by (please check one box): / q Dr. / q Insurance Provider / q Hospital
q Family / q Friend / q Website/Internet Search / q Yellow Pages / q Other
Spouse’s Name (if applicable):
Spouse’s phone number: ( )
Spouse’s date of birth: / / / Email Address (if applicable):
IN CASE OF EMERGENCY
Emergency Contact’s Name:
Additional Contact’s Name: / Address:
Address: / Relationship:
Relationship: / Phone Number:
( )
Phone Number:
( )
INSURANCE INFORMATION
(Please give your insurance card(s) to the receptionist)
Name of Primary Insurance: / Policy Number: / Group Number:
Policy Holder’s Name: / Birth date:
/ / / Policy Holder’s SSN: / Employer:
Patient’s relationship to policy holder: / q Self / q Spouse / q Child / q Other
Name of Secondary Insurance (if applicable): / Policy Number: / Group Number:
Policy Holder’s Name: / Birth date:
/ / / Policy Holder’s SSN: / Employer:
Patient’s relationship to policy holder: / q Self / q Spouse / q Child / q Other
Are you allergic to any medications? (If so please list or circle below)
q I have no known drug allergies
Latex Shellfish X-ray Dye Iodine
Are you on any medications? Please List:
Are you taking any blood thinners? q Aspirin q Plavix q Coumadin (Warfarin) q Fish Oil q Vitamin E
q Pradaxa
q Xeralto
Do you smoke or use tobacco products?
q YES q NO If yes, How many packs per day?
For how many years?
Do you drink alcoholic beverages?
q YES q NO If yes, How many drinks per day?
Do you drink caffeine (soda, coffee, etc.)?
q YES q NO If yes, How many drinks per day?
PATIENT PAST MEDICAL HISTORY: (Please list any medical conditions either current or past)
q Heart Disease / q Heart Attack / q Strokeq Diabetes
On Insulin? q YES
q NO / q Cancer (Please specify type) / q Hypertension (High Blood Pressure)
q High Cholesterol / q Prostate Cancer / q Depression
q Kidney Stones / q Kidney Disease / q Dialysis
q HIV/AIDS / q Parkinson’s / q Alzheimer’s
q Hepatitis A / B / C / q Liver Disease / q Epilepsy or Seizures
q Other:
PATIENT SURGICAL HISTORY: (Please list any surgeries you have had and the year they were performed)
Name of Surgery / Date of Surgery (Year)FAMILY MEDICAL HISTORY: (Please list any medical conditions in your family and specify which family member)
CONDITION / FAMILY MEMBER(mother, father etc) / CONDITION / FAMILY MEMBER
(mother, father etc)
q Heart Disease / q Prostate Cancer
q Diabetes / q Cancer
Type-
q Stroke / q High Cholesterol
q Alzheimer’s / q Parkinson’s
q Heart Attack / q Kidney Disease
q High Blood Pressure / q Dementia
q Other:
Review of Systems
Have you had any of the following problems recently?
GENERAL:
q Weight loss or gain q Fatigue q Sleep Apnea
q Fever or chills q Headaches q Other:
EYES:
q Blurry or double vision q Glaucoma q Cataracts
NEUROLOGICAL:
q Dizziness / q Numbness/Tingling / q Seizuresq Fainting / q Tremors / q Paralysis/ Weakness
ENDOCRINE:
q Excessive Thirst q Tired/Sluggish q Too Hot/Cold GASTROINTESTINAL:
q Abdominal Pain q Nausea/Vomiting q Stomach Ulcer CARDIOVASCULAR:
q Heart Trouble q Chest pain or discomfort q Heart Murmur
q High Blood Pressure q Shortness of Breath q Irregular Heart Beat
SKIN:
q Rash q Skin Lumps q Psoriasis
MUSCULOSKELETAL:
q Muscle or joint pain q Back Pain q Arthritis EAR/NOSE/THROAT/MOUTH:
q Sinus Problems q Vertigo q Hearing loss RESPIRATORY:
PSYCHOLOGIC:
q Depression q Anxiety q Suicidal Thoughts
FEMALE PREGNANCY HISTORY:
Number of Vaginal Deliveries
Number of Caesarians
AUA SYMPTOM SCORE (AUASS)
PATIENT NAME: TODAY’S DATE:
(Circle One Number on Each Line) / Not at All / Less Than 1Time in 5 / Less Than Half the Time / About Half the Time / More Than Half the Time / Almost Always
Over the past month or so, how often have you had a sensation of not emptying your bladder completely after you finished urinating? / 0 / 1 / 2 / 3 / 4 / 5
During the past month or so, how often have you had to urinate again less than two hours after you finished urinating? / 0 / 1 / 2 / 3 / 4 / 5
During the past month or so, how often have you found you stopped and started again several times when you urinated? / 0 / 1 / 2 / 3 / 4 / 5
During the past month or so, how often have you found it difficult to postpone urination? / 0 / 1 / 2 / 3 / 4 / 5
During the past month or so, how often have you had a weak urinary stream? / 0 / 1 / 2 / 3 / 4 / 5
During the past month or so, how often have you had to push or strain to begin urination? / 0 / 1 / 2 / 3 / 4 / 5
None / 1 Time / 2 Times / 3 Times / 4 Times / 5 or More Times
Over the past month, how many times per night did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning? / 0 / 1 / 2 / 3 / 4 / 5
Add the score for each number above and write the total in the space to the right. TOTAL:
SYMPTOM SCORE: 1-7 (Mild) 8-19 (Moderate) 20-35 (Severe)
QUALITY OF LIFE (QOL)
Delighted / Pleased / Mostly Satisfied / Mixed / Mostly Dissatisfied / Unhappy / TerribleHow would you feel if you had to live with your urinary condition the way it is now, no better, no worse, for the rest of your life? / 0 / 1 / 2 / 3 / 4 / 5 / 6
The IIEF-5 Questionnaire (SHIM)
Please encircle the response that best describes you for the following five questions:
Over the past 6 months:1. How do you rate / Very low / Low / Moderate / High / Very high
your confidence that you
could get and keep an / 1 / 2 / 3 / 4 / 5
erection?
2. When you had erections with sexual stimulation, how often were your erections hard enough
for penetration? / Almost never or never
1 / A few times
(much less than half the time)
2 / Sometimes
(about half the time)
3 / Most times
(much more than half the time)
4 / Almost always or always
5
3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated your partner? / Almost never of never
1 / A few times
(much less than half the time)
2 / Sometimes
(about half the time)
3 / Most times
(much more than half the time)
4 / Almost always or always
5
4. During sexual / Extremely / Very / Difficult / Slightly / Not difficult
intercourse, how difficult / difficult / difficult / difficult
was it to maintain your
erection to completion of
intercourse?
1 / 2 / 3 / 4 / 5
5. When you attempted sexual intercourse, how often was it satisfactory for you? / Almost never or never
1 / A few times
(much less than half the time)
2 / Sometimes
(about half the time)
3 / Most times
(much more than half the time)
4 / Almost always or always
5
Total Score:
1-7: Severe ED 8-11: Moderate ED 12-16: Mild-moderate ED 17-21: Mild ED 22-25: No ED