Urological Associates of the Pie

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? ____________________________________________

Medical History Page 2

fFAMILY HISTORY Please circle all that apply to your family.If yes, which family member?
Yes No	Diabetes	Yes No	Kidney Stones
Yes No	Prostate Cancer	Yes No	Abnormal Bleeding
Yes No	Heart Attack	Yes No	Tuberculosis
Yes No	Cancer	Yes No	Kidney Problems
Yes No	High Blood Pressure	Yes No
DO YOU HAVE OR HAVE YOU PREVIOUSLY HAD.... circle all that apply.
Yes No	Frequent or Severe Headaches
Yes No	Dizziness
Yes No	Blurred Vision
Yes No	Any other Vision Problems
Yes No	Decrease in Hearing
Yes No	Recurrent nose bleeds
Yes No	Chest Pain
Yes No	Heart Attack
Yes No	Irregular Heart Beat/Pacemaker
Yes No	Abnormal Bleeding tendency
Yes No	Asthma, Emphysema, Bronchitis
Yes No	Chronic or Frequent Cough
Yes No	Shortness of Breath
Yes No	High Blood Pressure
Yes No	elching or heartburn
Yes No	Stomach or colon disorders
Yes No	Nausea/vomiting/Diarrhea
Yes No	Vomited Blood
Yes No	Abdominal Cramping
Yes No	Change in size, shape, or texture of bowel movement
Yes No	Blood in bowel movement
Yes No	Backaches
Yes No	Tiredness or weight loss without apparent reason
Yes No	Cancer
Yes No	Any other medical problems not listed above
WOMEN ONLY Please circle or answer.
Date of last period __________Date of last pelvic examination/PAP smear _________ Any discharge from the vagina Yes No Are you pregnant Yes No How many pregnancies _____ C-Sections ______Vaginal Deliveries ________ Have you ever been diagnosed with endometriosis Yes No

Thank you for supplying us with this important information. Please remember to fill-out these forms and bring them with you for your appointment.