Academic Urology at Erlanger

Name: / Referring MD: / Date:
DOB: / Level of Education: / Occupation
Marital Status: / Ht: / Wt
Allergies:
Please describe your problem:
Location? / When did you first notice it?
Associated Symptoms?
Does anything improve it? / Make it worse?
Communication Issues: / Do you have an Advanced Directive?
Language Spoken: / Race:
EMAIL ADDRESS:
Circle any Medical Problems that apply: / Please list all surgeries / Year
Heart Disease / High Blood Pressure
Pacemaker/Defibrillator / Stroke/Seizure
Lung Disease / Kidney Problems
Diabetes / Bleeding Problems
Bowel Problems
Medication / Dose / Frequency / Medication / Dose / Frequency
Have you ever or do you use the following? / Occupation?
Tobacco? / Alcohol? / Drugs?
Family History of diseases

Please check if you have ever had any of the following symptoms:

General / ENT / Respiratory / Neurologic / Genitourinary
□ Fever / □ Hearing loss / □ Short of breath / □ Dizziness / □ Painful urination
□ Chills / □ Dentures / □ Chronic Cough / □ Numbness/tingle / □ Frequent or urgent urination
□ Headaches / □ Nose bleeds / □ Emphysema / □ Difficult balance / □ Urine leakage
□ Weight Loss / □ Sore throat / □ Tuberculosis / List Other: / □ Urinary tract infections
List other: / List other: / List other: / □ Blood in Urine
Psychological / □ Kidney problems
Eyes / Cardiovascular / Gastrointestinal / □ Depression / For Men / For Women
□ Double vision / □ Chest pain / □ Abdominal Pain / □ Anxiety / □ Erection problems / # pregnancies
□ Glaucoma / □ Heart disease / □ Constipation / List Other: / □ Testicular lump
□ Blurred vision / □ Blood pressure / □ Diarrhea / □ Prostate procedure / # vaginal deliveries
List other: / □ Heart murmur / □ Rectal bleeding / Hematologic / □ Elevated PSA
□ Ankle swelling / □ Use Antacids / □ Clotting Disease / List other: / Difficult deliveries?
List other: / List other: / □ Anemia
Patient Name / DOB / Home phone number / Cell phone number / Work Phone number

Academic Urology Permission Form

May we leave medical information on your voicemail or answering machine? (circle) Y N

In the event that we are unable to contact YOU, please list the names and phone numbers of any family member(s) or friends that we may discuss your patient information with; by signing this form, you are giving Academic Urology permission to speak with and/or leave messages regarding test results, procedure scheduling, future appointments, medication issues, or any other instructions on your voicemail or with the person(s) listed below. This information will remain effective for the duration of your care unless terminated in writing by you.

Authorized Person(s) / Relationship / Phone Number
1.
2.
3.
4.

PATIENT SIGNATURE: ______DATE: ______

PATIENT INFORMATION

Name: / DOB:
SSN: / Address:
City/State: / Zip:
Home phone number: / Cell phone number:
Is it okay to leave a voicemail/message on your phone regarding medications, labs, appointments, or instructions? Y N
Employer: / Address:
Work phone number: / City/State: / Zip:

INSURANCE

Primary Insurance: / Subscriber:
Relationship: / DOB: / SSN:
Secondary Insurance: / Subscriber:
Relationship: / DOB: / SSN:

EMERGENCY CONTACTS

Name: / Relationship:
Address: / City/State: / Zip:
Home phone: / Cell phone: / Is it okay to leave a voicemail/message on your phone regarding medications, labs, appointments, or instructions? Y N
Name: / Relationship:
Address: / City/State: / Zip:
Home phone: / Cell phone: / Is it okay to leave a voicemail/message on your phone regarding medications, labs, appointments, or instructions? Y N

PHARMACY

Pharmacy Name:
Phone: / Fax:
Medication/Food Allergies:

PHYSICIANS

(Please list first and last name)

Primary Care: / Phone: / Fax:
Referring Physician: / Phone: / Fax:
Cardiologist: / Phone: / Fax:
Other: / Phone: / Fax:

Academic Urology at Erlanger

Bladder Questionnaire

Please check or indicate the appropriate response for each question

1. Do you ever leak urine or lose control of urination?  Yes  No

2. If you lose control, do you know when it happens or do you find yourself wet?

 Know when it happens  Find myself wet

3. How often do you lose control and wet yourself or your pads?

When you cough or sneeze?  Never  Monthly  Weekly  Daily

When you engage in physical activity?  Never  Monthly  Weekly  Daily

When you raise yourself from sitting?  Never  Monthly  Weekly  Daily

When you rise to standing position?  Never  Monthly  Weekly  Daily

4. How often do you wear pads or other forms of protection because of wetting?

 Never  Monthly  Weekly  Daily

5. On average, how many pads do you use a week? ______

6. On average, how wet are you when you change your pads?  Dry  Moist  Damp  Wet

7. How bad does loss of urinary control bother you on a scale from 1 to 10? ______

8. How often must you push or strain to start urinating?  Never  Monthly  Weekly  Daily

9. How would you describe the usual force of your urinary stream?

 Strong  Weak  Interrupted  Dribbling

10. How often do you lose control of urination and wet yourself or your pads because you feel a strong urge

and cannot stop it?  Never  Monthly  Weekly  Daily

11. How many pregnancies have you had? ______

How many vaginal deliveries? ______

How many c-section deliveries? ______