new patient registration form - potomac urology urology new male... · chief complaint: ......
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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
Street Address Apt # City State Zip Code
Home Address: ___________________________________________________________________________________________________
Patient's Employer/School: _______________________ __________________________________________________________________
Primary Insurance: ______________________________________________________________________________________
ID Number: _____________________ Group Number: ____________________
Subscriber's Name: _____________________________ Subscriber DOB: _____/_____/_____
Street Address Apt # City State Zip Code
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
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.
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
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.
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: ____________________
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 = __________
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.
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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
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.