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Cascadesurologycenter.com

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

Source: http://www.cascadesurologycenter.com/medicalform.pdf

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