NEW PATIENT REGISTRATION FORM - Potomac Urology Urology new MALE... · CHIEF COMPLAINT: ... Arthritis COPD Hepatitis C Mitral valve prolapse Thyroid disease ... Liver disease Spinal

www.potomacurology.com 2296 Opitz Blvd., Suite 350 Tel: 703-680-2111 4660 Kenmore Ave., Suite 1120Woodbridge, VA 22191 Fax: 703-878-3939 Alexandria, VA 22304

Alok Desai, M.D. Pratik Desai, M.D. Nilay Gandhi, M.D. John Klein M.D. Inderjit Singh M.D.

NEW PATIENT REGISTRATION FORM

Street Address Apt # City State Zip Code

Name Relationship


Home Address: ___________________________________________________________________________________________________

Patient's Employer/School: _______________________ __________________________________________________________________

Primary Insurance: ______________________________________________________________________________________

ID Number: _____________________ Group Number: ____________________

Subscriber's Name: _____________________________ Subscriber DOB: _____/_____/_____


Subscriber's Address: __________________________________________________________________________________________

_________________________________ _________________________________ _____/_____/_____ _____/_____/_____Patient/Parent Signature Printed Name DOB Date

Subscriber's Name: _____________________________ Subscriber DOB: _____/_____/_____

Social Security Number: _____ - _____ - ____ Relationship to patient: __________

Subscriber'sEmployer: _________________________ Phone: (_____) _____-_____

Subscriber's Address: __________________________________________________________________________________________

Secondary Insurance: ______________________________________________________________________________________

ID Number: _____________________ Group Number: ____________________

Social Security Number: _____ - _____ - ____ Relationship to patient: __________

Subscriber'sEmployer: _________________________ Phone: (_____) _____-_____

Patient Name: ___________________________________________________ Last First MI

Home Phone: (_____) _____-_____ Cell Phone: (_____) _____-_____ Work Phone: (_____) _____-_____

Street Address City

Phone: (_____) _____-_____

State Zip Code

Emergency Contact: _____________________ _______________

Phone: (_____) _____-_____Pharmacy: _________________________________ __________________________ Name City State

http://www.potomacurology.com/

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How did you hear about us?

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Facebook Google Hospital follow-up Insurance company Primary Care doctor _________________

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Referring physician ______________ Website Word of mouth Yelp OTHER: _______________________

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DOB: ______ / ______ / ______ Sex: ______ Marital Status: Single Married Divorced Widowed SSN: ______ - ______ - ______ Email: ____________________________________________________________________

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Race: American Indian Asian Native Hawaiian/Pacific Island Black/African American White Hispanic Other _________

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Language: English Other _________



Medication Strength/Dose # of times per day taken

Please list Drug Allergies: ___________________________________________________

MEDICATIONS: Please list any prescription medications, over-the-counter medications, and vitamin supplements you take routinely:

Are you taking Aspirin, Plavix, or any other form of Blood Thinners? Yes No

Please complete the MEDICATION page if taking more than 4 medications

CHIEF COMPLAINT: _________________________________________________________________

MEDICAL HISTORY: Please CHECK any of the following conditions which YOU have had or currently have:

Anemia CHF (heart failure) Heart attack (MI) Low Testosterone Seizures

Arthritis COPD Hepatitis C Mitral valve prolapse Thyroid disease

Asthma CAD (heart disease) High blood pressure (HTN) MRSA infection Tuberculosis

BPH CVA (stroke) High cholesterol Multiple sclerosis Vascular disease

Cancer: Depression Inflammatory Bowel (IBD) Osteoporosis Other:

Type ___________ Diabetes Irritable Bowel (IBS) Parkinson's disease _________________

Chest pain GERD/Acid reflux Kidney stones Positive PPD _________________

Chronic UTI's Gout (high uric acid) Liver disease Spinal cord injury _________________

SURGICAL HISTORY:

Please CHECK any procedures YOU have had and the date of the procedure:

Heart stent Vasectomy

YEAR YEAR MALES ONLY YEAR

Adrenalectomy Hernia repair Brachytherapy

Appendectomy Hip replacement Circumcision

Gall bladder Ureteral stent TURP

Gastric bypass OTHER: Varicocele ligation

Back Surgery Knee replacement Hernia repair

Bladder augment Laparoscopy Hydrocelectomy

Bladder removal Lithotripsy Laser of prostate

CABG Liver biopsy Orchiectomy

Colectomy Kidney removal Penile prosthesis

Colon surgery Pacemaker Prostate biopsy

Cystoscopy Perc stone removal Prostatectomy

ESWL Kidney stone removal Spermatocelectomy


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REVIEW OF SYSTEMS:

Endocrine Ear/Nose/Throat/Mouth Gynecologic

Skin rash Yes No Sexually active Yes No Tremors Yes NoBoils Yes No Pain w intercourse Yes No Dizzy spells Yes NoPersistent rash Yes No Leaking urine with Numbness Yes NoOther: ___________________ intercourse Yes No Headache Yes No

Gastrointestinal Hematologic/Lymphatic Eyes

Integumentary Sexual History Neurologic

FAMILY HISTORY:

SOCIAL HISTORY:

Recreational drug use: No Yes (_____________________) Exercise: No Yes (_____________________)

Smoking: Current smoker (Packs/day: ____ , # years: ____) Former smoker (Year quit _____) Non-smoker

Sexually active: No Yes Occupation: _______________________________

Caffeine: No Yes (_____________________) Alcohol: No Yes (_____________________)

Do you have any problems NOW related to the following systems? Please CHECK YES or NO.

Constitutional Symptoms Cardiovascular RespiratoryFever Yes No Chest pain Yes No Wheezing Yes NoChills Yes No Varicose veins Yes No Frequent cough Yes NoHeadache Yes No High blood pressure Yes No Shortness of breath Yes NoWeight gain/loss Yes No Low blood pressure Yes No

Excessive thirst Yes No Ear infection Yes No Heavy periods Yes NoToo hot/cold Yes No Sore throat Yes No Irregular periods Yes NoTired/sluggish Yes No Sinus problems Yes No Menopause Yes NoOther: ___________________ Other: __________________________ Hormone therapy Yes No

Abdominal pain Yes No Swollen glands Yes No Blurred vision Yes NoNausea/vomiting Yes No Blood clotting problem Yes No Cataracts Yes NoIndigestion Yes No Pulm embolism Yes No Double vision Yes NoHeartburn Yes No Anemia Yes No Other: ____________________Constipation Yes No HIV/AIDS Yes NoIBS Yes No Other: __________________________Diarrhea Yes NoRectal bleed Yes NoOther: ____________________


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Father Mother Brother Sister Uncle/Aunt Grandparents

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Alive? Age Bladder cancer Kidney cancer Prostate cancer Kidney stones Diabetes Stroke

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INTERNATIONAL PROSTATE SYMPTOM SCORE (IPSS) ***MALE PATIENTS ONLY***Over the past MONTH, how often have you…. Not at all Less than

1 time in 5Less than

half the timeAbout half

the timeMore than

half the timeAlmostAlways

1. ...had a sensation of not emptying your bladder completelyafter you finished urinating?

0 1 2 3 4 5

2. ...had to urinate again less than two hours after you finishedurinating?

0 1 2 3 4 5

3. ...found you stopped and started again several times whenyou urinated?

0 1 2 3 4 5

4. ...found it difficult to postpone urination? 0 1 2 3 4 5

5. ...had a weak urinary stream? 0 1 2 3 4 5

6. ...had to push or strain to begin urination? 0 1 2 3 4 5

None 1 time 2 times 3 times 4 times 5 times ormore

7. Over the past month, how many times per night did you mosttypically 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

TOTAL SCORE = __________

QUALITY OF LIFE (QOL) Delighted Pleased MostlySatisfied

Mixed MostlyDissatisfied

Unhappy Terrible

How would you feel if you had to live with your urinarycondition the way it is now, no better, no worse, for the

rest of your life?

0 1 2 3 4 5 6

INTERNATIONAL INDEX OF ERECTILE FUNCTION (IIEF) ***MALE PATIENTS ONLY***Over the past 6 MONTHS, ... Very Low Low Moderate High Very High

1. ...how do you rate your confidence that you could get and keep anerection?

1 2 3 4 5

Almost never ornever

A few times(much less

than half thetime)

Sometimes(about halfthe time)

Most times(much morethan half the

time)

Almost alwaysor always

2. ...when you had erections with sexual stimulation, how often wereyour erections hard enough for penetration?

1 2 3 4 5

3. ...during sexual intercourse, how often were you able to maintainyour erection after you had penetrated your partner?

1 2 3 4 5

Extremelydifficult

Very difficult Difficult Slightlydifficult

Not difficult

4. ...during sexual intercourse, how difficult was it to maintain yourerection to completion of intercourse?

1 2 3 4 5

Almost never ornever

A few times(much less

than half thetime)

Sometimes(about halfthe time)

Most times(much morethan half the

time)

Almost alwaysor always

5. ...when you attempted sexual intercourse, how often was itsatisfactory for you?

1 2 3 4 5

TOTAL SCORE = __________



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MEDICATIONS: Please list any prescription medications, over-the-counter medications, and vitamin supplements you take routinely:

Medication Strength/Dose # of times per day taken



Documents

NEW PATIENT REGISTRATION FORM - Potomac Urology Urology new MALE... · CHIEF COMPLAINT: ... Arthritis COPD Hepatitis C Mitral valve prolapse Thyroid disease ... Liver disease Spinal