Male New Patient Form
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- Words: 300
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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: Enlarged Prostate Blood in urine High PSA Bladder Infection Kidney Stones Prostate Infection Urinary Incontinence Bladder Cancer Prostate Cancer Erectile Dysfunction Overactive Bladder Infertility Lump in Testicle Other ___________________________________________ My Symptom(s) are: Weak Stream Frequency Urgency Painful Urination Chest Pain Blurred Vision
Not emptying Bladder Blood in Urine Testicle Pain Pain in Side, R / L Thirst Cough
Medical / Surgical History Diabetes Hypertension Heart Attack Heart Murmur Strokes Gallbladder Emphysema Cancer ______________ Hernia Prostate Biopsy Other _________________
Leakage Bladder Pain Straining Fever Vomiting Bleeding
Urinating @ Night # ___ Abdominal Pain Weakness/Legs Back Pain Weight Loss Other ________________
Prostate Surgery Prostate Seeding Appendectomy Hepatitis Cystoscopy
Heart Bypass Lithotripsy Kidney Stone Surgery Parkinson’s Back/Hip/Knee
Medications None Flomax Proscar Detrol Vesicare Avodart Uroxatrol Hytrin Lupron/Eligard Aspririn Antibiotic: _______________________ Other: _____________________________________________________________________________ Allergies None PCN Sulfa Cipro Iodine/contrast Other ____________________________________________________ Family History: Prostate Cancer
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: ____________________________________
Male New Patient Form – 7/2007
Date: ________________
MRN: _________________ Medical Doctor/PCP: ______________________________________ Who referred you: ________________________________________________________________ When did the problem begin: ________________________________________________________ My Main Problems are: Enlarged Prostate Blood in urine High PSA Bladder Infection Kidney Stones Prostate Infection Urinary Incontinence Bladder Cancer Prostate Cancer Erectile Dysfunction Overactive Bladder Infertility Lump in Testicle Other ___________________________________________ My Symptom(s) are: Weak Stream Frequency Urgency Painful Urination Chest Pain Blurred Vision
Not emptying Bladder Blood in Urine Testicle Pain Pain in Side, R / L Thirst Cough
Medical / Surgical History Diabetes Hypertension Heart Attack Heart Murmur Strokes Gallbladder Emphysema Cancer ______________ Hernia Prostate Biopsy Other _________________
Leakage Bladder Pain Straining Fever Vomiting Bleeding
Urinating @ Night # ___ Abdominal Pain Weakness/Legs Back Pain Weight Loss Other ________________
Prostate Surgery Prostate Seeding Appendectomy Hepatitis Cystoscopy
Heart Bypass Lithotripsy Kidney Stone Surgery Parkinson’s Back/Hip/Knee
Medications None Flomax Proscar Detrol Vesicare Avodart Uroxatrol Hytrin Lupron/Eligard Aspririn Antibiotic: _______________________ Other: _____________________________________________________________________________ Allergies None PCN Sulfa Cipro Iodine/contrast Other ____________________________________________________ Family History: Prostate Cancer
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: ____________________________________
Male New Patient Form – 7/2007
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