CASCADES UROLOGY CENTER
Note: This is a confidential record and will be kept in our office. Information contained here will not be released to anyone without your authorization to do so.
Last Name: _______________________________ First Name: ______________________ Middle Name: ________________
Age: ________ Date of Birth: _____/_____/_______ Marital Status: S M D W Referral: ______________________
___________________________________________________________________________________________________________ HISTORY OF THE PRESENT ILLNESS
What is the main reason for your visit to our office (Describe your problem in detail)_______________________________________
___________________________________________________________________________________________________________
Days _________ Weeks ________ Months _______ Other ________________
Minutes _______Hours ________ Constant ______ Other ________________
Is anything else occurring at the same time?
Nausea _______ Bleeding ______ Fever _________ Other ________________
Have you had similar problem in the past?
No _____ Yes _____ How long ago? _____ Any treatment? ________
PLEASE MARK/ CIRCLE ALL THAT APPLY Office use: Sto( )-Blo( )-Dys( )-UTI( )-GU surg( )-AUASx( )-PSA( )Past MEDICAL ILLNESSES that apply: If NONE, please mark here ( )
# times: ___________ Symptoms: burning / frequency / pressure / blood in urine / antibiotic helped
( ) – Blood in the urine # times: ___________ ( ) gross blood (urine was red)
Had previous prostate biopsy: ( )Benign ( )Malignant
# times: ___________ Side: Right / Left ( ) Passed spontaneously
( ) – Any urologic malignancy: ________________________________________________________________________________
( ) – Problems urinating ( ) Difficulty urinating ( ) couldn’t urinate and had catheter placed ( ) couldn’t hold and needed pads
( ) Stroke ( ) Cancer: ___________________ ( ) Diabetes ( ) Glaucoma ( ) Heart problems ( ) High blood pressure
( ) Have children How many: _______ # times pregnant: _____ # Vaginal deliveries: _____ # C-Sections: _____ Other: _______
Other medical problems: ____________________________________________________________________________________
___________________________________________________________________________________________________________
Please list ALL previous SURGERIES that apply: If NONE, please mark here ( )
Type:__________________ Side: Right____/Left____ # times:________ Year(s)________
Type:_______________________ ( )Benign ( )Malignant: Radiation___
Type: vag X abd How many times? ____ Year(s):______
Type: vag X abd Year: ________ ( )Benign ( )Malignant: Radiation___/Chemo___
( ) Scrotum/testicle surgery ___________________________
How many times: _____________ ( )Cervical ( )Lumbar
( ) – Any other urologic surgery:________________________________________________________________________________
( ) – Any other surgeries: ____________________________________________________________________________________ Please CIRCLE if you TAKE any of the following MEDICATIONS If NONE, please mark here ( )
Aspirin -Coumadin (warfarin) – Plavix - Motrin, Advil (ibuprofen) - Flomax - Uroxatral - Hytrin (terazosin) - Cardura (doxazosin)
Minipress (prazosin) - Proscar (finasteride) - Avodart - Detrol – Ditropan (oxybutinin)- Oxytrol patch - Vesicare – Enablex – Levsin
Please list ALL other medications you are taking: ________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Please CIRCLE if you are ALLERGIC to the following MEDICATIONS If NONE, please mark here ( )
Codeine - Iodine topical – Iodine dye(x-ray contrast) – Latex - Lidocaine gel - Nitrofurantoin(Macrodatnin/Macrobid) - Penicillin –
Sulfa(Bactrin) What other medications are you allergic to? ________________________________________________________
__________________________________________________________________________________________________________
Please CIRCLE all FAMILY illnesses (add relationship if positive) If NONE, please mark here ( )
( ) Prostate Cancer ________________ ( ) Kidney stones ______________ ( ) Cancer ______________ ( ) Diabetes ___________
Other family illnesses: ________________________________________________________________________________________
Please MARK/CIRCLE what applies to your HABITS/PERSONNAL: If NONE, please mark here ( )
How much: _____ packs/day for _____years; Quit ______ years/months ago
Regular_____ Decaf_____ How much: ______ cups/day
Other: _____________________________________________
REVIEW OF SYSTEMS : Do you now or have you had any problems related to the following systems ? Circle Yes or No Allergies Integumentary Cardiovascular Gastrointestinal Musculoskeletal Constitutional Genitourinary Neurological Ear/Nose/Throat/Mouth Psychiatric Endocrine Hematologic Respiratory
Blood clotting probl. Y N Frequent cough Y N
Swollen glands Y N Shortness of breath Y N
Luis Ariel del Val María Silvina Gómez Laura Polka Servicio de Hematología y Hemoterapia Departamento de Hemostasia y Trombosis Instituto Modelo de Cardiología Privado SRL La anticoagulación oral es un procedimiento médico en cons-tante avance. Los anticoagulantes orales más empleados actualmen-te continúan siendo los cumarínicos que inhiben el ciclo biológic
To ask or not to ask? The role of research in the NPD process Leaf through any marketing text-book and you will find at least one chapter devoted to the role of research in the brand and product development process. A concise summary of this chapter would probably conclude that the primary function of Market Research is to give valuable insight and validation to the teams tasked with satisfying