Female New Patient Form
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The Shappley Clinic Patient Name: ________________________________________
Date: ________________
MRN: _________________ Medical Doctor/PCP: ______________________________________ Who referred you: ________________________________________________________________ When did the problem begin: ________________________________________________________ My Main Problems are: Leak Urine Blood in urine Dropped Bladder Bladder Pain Kidney Stones Bladder Cancer Overactive Bladder Interstitial Cystitis Bladder Infection Other ___________________________________________ My Symptom(s) are: Leak w/ Cough Frequency Urgency Painful Urination Chest Pain Blurred Vision
Not emptying Bladder Blood in Urine Urinating @ Night # ___ Pain in Side, R / L Thirst Cough
Medical / Surgical History Diabetes Hypertension Heart Attack Heart Murmur Strokes Gallbladder Emphysema Cancer Pregnant C-Section # ____ Sling (TVT) Back/Hip/Knee
Pads # ___ Bladder Pain Weak Stream Fever Vomiting Bleeding
Urge Leakage Abdominal Pain Weakness/Legs Back Pain Weight Loss Other ________________
Bladder Tack Hysterectomy Appendectomy Hepatitis Menopause Cystoscopy
Heart Bypass Vaginal Deliveries # _____ Kidney Stone Surgery Parkinson’s Last Period: __________ Other _________________
Medications None Detrol Vesicare Aspirin Antibiotic: _______________________ Others: _________________________________________________________________________ ___________________________________________________________________________________ Allergies None PCN Sulfa Cipro Iodine/contrast Other ____________________________________________________ Family History: Kidney Cancer
Kidney Stones
Heart Disease
Social History: Smoke If yes, how many packs per day: __________ Single
Married
Alcohol Use: Social Retired
Divorced
Widowed
Number of Children: ________
Light
Moderate Excessive
Occupation: ____________________________________
Female New Patient Form – 7/2007
Date: ________________
MRN: _________________ Medical Doctor/PCP: ______________________________________ Who referred you: ________________________________________________________________ When did the problem begin: ________________________________________________________ My Main Problems are: Leak Urine Blood in urine Dropped Bladder Bladder Pain Kidney Stones Bladder Cancer Overactive Bladder Interstitial Cystitis Bladder Infection Other ___________________________________________ My Symptom(s) are: Leak w/ Cough Frequency Urgency Painful Urination Chest Pain Blurred Vision
Not emptying Bladder Blood in Urine Urinating @ Night # ___ Pain in Side, R / L Thirst Cough
Medical / Surgical History Diabetes Hypertension Heart Attack Heart Murmur Strokes Gallbladder Emphysema Cancer Pregnant C-Section # ____ Sling (TVT) Back/Hip/Knee
Pads # ___ Bladder Pain Weak Stream Fever Vomiting Bleeding
Urge Leakage Abdominal Pain Weakness/Legs Back Pain Weight Loss Other ________________
Bladder Tack Hysterectomy Appendectomy Hepatitis Menopause Cystoscopy
Heart Bypass Vaginal Deliveries # _____ Kidney Stone Surgery Parkinson’s Last Period: __________ Other _________________
Medications None Detrol Vesicare Aspirin Antibiotic: _______________________ Others: _________________________________________________________________________ ___________________________________________________________________________________ Allergies None PCN Sulfa Cipro Iodine/contrast Other ____________________________________________________ Family History: Kidney Cancer
Kidney Stones
Heart Disease
Social History: Smoke If yes, how many packs per day: __________ Single
Married
Alcohol Use: Social Retired
Divorced
Widowed
Number of Children: ________
Light
Moderate Excessive
Occupation: ____________________________________
Female New Patient Form – 7/2007
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