Urological Associates of the Piedmont
  Adult and Pediatric Urology

Offices in Culpeper and Warrenton, Virginia
 

 1100 Sunset Lane Suite 1211A
Culpeper, Va. 22701
540-825-2900
410 Hospital Drive, Warrenton, Va. 20186 
540-347-1314 

 

Medical History 1(Printable form)

( Please read, sign, and return to our office )

Name______________________________________________Date________________
Age________        Date of Birth__________________Place of Birth_________________
Marital Status:  Single __________  Married _____   Divorced __________Widowed _______ 
Present or former Employer ____________________________________________________
Date of last physical _______________Name of Doctor ______________________________

PERSONAL MEDICAL HISTORY 
(Have you ever suffered from any of the following? Please    circle Yes or No.)
 
Yes    No Rheumatic Fever Yes    No Epilepsy, Seizure, Convulsion
Yes    No Tuberculosis Yes    No Heart Disease
Yes    No Thyroid Problems Yes    No Diabetes
Yes    No Hepatitis/Liver Problems Yes    No Cancer
Yes    No Arthritis, Rheumatism,Gout Yes    No Depression/Nervous Breakdown, Emotional Problems
Yes    No Any Bone or Joint Disease Yes    No Hay Fever/Asthma
Yes    No Gall Bladder Disease Yes    No AIDS
   
Drug Allergies--to which medicines are you allergic? Any annesthesia complications?
_____________________________________________________________________________
_____________________________________________________________________________
List of Medicines you take. Include Dosage and frequency.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Weight____________  Weight one year ago____________Height____________
SURGERY, MAJOR INJURIES, TESTS--(example- heart blood vessel catherization)
Type__________________________________________ Year  ________________________
Type__________________________________________ Year  ________________________
Type__________________________________________ Year  ________________________
Type__________________________________________ Year  ________________________		  
   
Do you Smoke  Yes   No  If you smoke, how many packs/day ____ How many years _____
Do you consume alcohol  Yes  No   If so, how many drinks per week ________
Have you had any drug or alcohol dependency problems __________________		  
X-RAY
Have you ever had a X-ray, CT Scan, or Ultrasound of your urinary tract   Yes  HO
What kinds of x-rays? ________________________________________________________
Where and when were they done? ____________________________________________
 
 

 


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