DELAWARE VALLEY UROLOGY, LLC

Patient Information Last Name: Home Phone # First Name, MI: Work Phone # Address 1: Cell Phone # Address 2: City, State, Zip Social Security #: Date of Birth: Age: Gender: [ ] Male [ ] Female Marital Status: [ ] M [ ] S [ ] D [ ] W Employer: Employment: [ ] FT [ ] PT Employer Address: Referring Dr. Student: [ ] Yes [ ] No Primary Care Dr. E-mail: Emergency Contact (not living with you): Emergency Contact Residence State: Emergency Contact Home Phone #: Relationship to Patient: Emergency Contact Work Phone #: Emergency Contact Cell Phone #: Spouse (parent/guardian if minor): Spouse’s Date of Birth: Spouse’s/Parent’s Employer: Phone #: Spouse/Parent/Guardian Employer Address: Pharmacy Name & City: Pharmacy Phone #: Do you have a Living Will? [ ] Yes [ ] No Do you have a Power of Attorney? [ ] Yes [ ] No How did you hear about our practice: [ ] Ad [ ] Doctor [ ] Yellow Pages [ ] Website [ ] Hospital [ ] Family/Friend [ ] Insurance Carrier [ ] Other

PAYMENT AUTHORIZATION

I hereby authorize my benefits to be paid directly to Delaware Valley Urology, LLC and am financially responsible for non-covered services and/or balances not paid by the insurance carrier. I also authorize release of my income information required to process these claims. I authorize you to give me medical care, including diagnosis and/or treatment (medical and/or surgical) In addition, I understand that I may be charged a $25.00 fee for any missed appointment ($100.00 for procedures) that is not cancelled by 3:00 p.m. on the business day before my scheduled appointment. ________________________________________________________ _________________________ Signature Date

PLEASE PRESENT YOUR INSURANCE CARD(S) AND DRIVERS LICENSE OR IDENTIFICATION AT CHECK IN.

Insurance Information Primary Insurance: Effective date: Expiration date: Subscriber: Patient’s relationship: [ ] self [ ] spouse [ ] child Policy #: Patient’s Policy suffix: Group Name: Subscriber’s Policy suffix: Group No.: Policy telephone #: Secondary Insurance: Effective date: Expiration date: Subscriber: Patient’s relationship: [ ] self [ ] spouse [ ] child Policy #: Patient’s Policy suffix: Group Name: Subscriber’s Policy suffix: Group No.: Policy telephone #:

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DELAWARE VALLEY UROLOGY, LLC Chart No.: __________

PATIENT NAME: __________________________________ AGE: ____ Today’s Date: __________ REASON FOR VISIT: _____________________________________________________________ REQUESTING PHYSICIAN: __________________________________

PERSONAL HISTORY:

Allergy History: Medication allergies: Yes No If Yes, list medication and reaction: __________________________________________________________________________________ Topical iodine Allergy: Yes No Latex Allergy: Yes No Allergic to IV contrast/X-ray ‘dye’ (used in imaging studies)? Yes No Other allergies: _____________________________________________________________________

Family History: Relation Living Deceased Age Cause of Death Mother Father Siblings Siblings Family urologic history. ______________________________________________________________

Past Medical History: Do you have? Poor vision Poor hearing Language barrier Religious/cultural barrier Do you have any metal implants (such as plates, screws, clips, pacemaker, joints etc.)? Yes No Do you have mitral valve prolapse or valvular disease? Yes No Do you require premedication with antibiotics before a dental procedure? Yes No Have you ever had a blood transfusion? Yes No Have you ever had Hepatitis? Yes No If yes, which type of Hepatitis? A B C Other Have you ever had a blood test for HIV (AIDS)? Yes No If yes, results were positive or negative

Hospitalizations / Surgeries

Year Hospital Surgeon Reason

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Urologic History: Do you now or have you had any of the following in the past? Please explain any Yes answers in space provided Y N Y N Y N

Blood In Urine Kidney Stones MALES ONLY Painful Urination/ Burning Frequent Urinary

Infections (UTI) Blood in semen

Urinary Frequency Incontinence Trouble with erections How often? _____ times/day Leak urine when sneezing -Prior treatment for erection

dysfunction

Waking to urinate? -How many pads/day? ___ Elevated PSA -How often? ___times/night -Aware of wetting? Problems with ejaculation Urinary Urgency Venereal Disease Decrease desire for sex Urine Retention Urethral Discharge Testicular Pain Intermittent stream Vaginal Discharge Ejaculatory Pain Feeling not completely emptying

Kidney Disease Prostate infections

Long wait or hesitation starting urinating

Flank / Kidney Pain/ Abdominal Pain

Enlarged Prostate/ BPH

Straining or pushing to urinate/ Difficult Voiding/ Slow stream

Other:

Other History: Do you now or have you had any of the following in the past? Please explain any Yes answers in space provided Y N Y N Y NAtrial fibrillation Ulcerative Colitis Arthritis Heart Attack Diverticulosis Seizures Abnormal Heart Beat Diverticulitis Stroke Coronary Artery Disease Crohn’s Parkinson’s Disease High Cholesterol Irritable Bowel Anemia High Blood Pressure Liver Disease (non alco) Migraines Heart Murmur Diabetes GYNECOLOGIC (Females) Phlebitis Thyroid Disease Number of Pregnancies: _______ Heart Failure Gout Last Menstrual Period: _______ Rheumatic Heart Disease Asthma Last GYN evaluation: ________ Cancer of ________ Bronchitis Endometriosis Glaucoma Emphysema Ectopic pregnancies Cataract Tuberculosis Abortions Acid reflux Pneumonia Peptic Ulcers Hay Fever

Other GYN Concerns:

Social History: Have you ever smoked? Yes No Amount per day: ____________________ How long have you or did you smoke? ______________________When did you quit smoking? ____________________ Have you ever injected illegal drugs? Yes No Do you drink alcohol? Yes No Amount per day: _________________ Your Occupation: ________________________________ Marital Status: Single Married Divorced Widowed Do you have children? Yes No What are their ages: ___________ Your Hobbies: ___________________________________________________________________

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Medications (Please include all drugs, i.e. Over-the-Counter, Non-Prescription or Herbal Drugs. Also, include any blood thinners such as Coumadin, Ticlid, Persantine, Plavix, or Aspirin):

Medication Dosage How Often? Medication Dosage How Often?

CURRENT MEDICAL CONDITIONS (Review of Systems): Y N Y N Y N

GENERAL RESPIRATORY Neck Pain or problems Weight Loss Chronic Cough NEUROLOGICAL Chills Shortness of Breath Numbness/Tingling Fatigue Spitting Up Blood Dizziness Fever Wheezing Headaches SKIN CARDIOVASCULAR Tremors Persistent Itch Chest Pain Light Headed Skin Rash Swelling of Feet or ankles PSYCHIATRIC Boils Varicose Veins Anxiety Breast Lumps GASTROINTESTINAL Depression

HEAD /EYES /EARS /NOSE /THROAT

Diarrhea / chronic Insomnia

Blurred Vision Abdominal Pain Memory Loss Double Vision Constipation ENDOCRINE Eye Pain Heartburn / Indigestion/ Excessive Thirst Hearing Loss Nausea/Vomiting Too Hot/Cold Ear Infection Rectal Bleeding Hormone Problem Nose Bleeds Loss of Appetite

HEMATOLOGIC

Sinus Problems Other GI Concerns Easy Bleeding Sore Throat MUSCULOSKELETAL Easy Bruising

NECK Back Pain Swollen Glands Neck Pain Joint Pain Blood Clotting Problem Swollen Glands Muscle Weakness Please explain all “Y” (Yes) answers (use back of page if necessary): ____________________________________________________________________________ Details of ROS (To be completed by Physician): ____________________________________________________________________________

Physician Signature: ___________________________________________ Date: _____________