Fillable New Patient Intake Form | Demographic Information

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New Patient Intake Form | Demographic Information

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Tanglewood Professional Center Riverwalk Professional Park Lakewood Ranch MOB II
5809 21
st
Avenue West 200 3
rd
Avenue West, Suite 210 6310 Health Park Way, Suite 100
Bradenton, Fl 34209 Bradenton, Fl 34205 Lakewood Ranch, Fl 34202
Phone: (941) 792-0340 | Fax: (941) 794-2251 | Website: www.urology-partners.com | Email: info@urology-partners.com
Bryan Allen, MD
Sean Castellucci, DO
Edward Herrman, MD
Ricardo D. Gonzalez, MD
G. Austin Hill, MD
Alan K. Miller, MD, FACS
Mark Weintraub, MD
Mitchell Yadven, MD
New Patient Intake Form | Demographic Information
Patient Name (please print): ________________________________ D.O.B. _____/_____/_____
Patient Phone: H: (____)_____-______ M: (____)_____-_______ Preferred Contact: ☐ H ☐ M
Email Address: __________________________________ SSN: ____-___-_____ Sex: ☐ F ☐ M
Marital Status: ☐ M ☐ S ☐ W ☐ D | Children: ☐ Y ☐ N # _____ | Ethnicity: ☐ Asian
☐ Black/African American ☐ Hispanic/Latino ☐ White/Not Hispanic ☐ Other Race
☐ Am. Indian/Alaskan Native ☐ Native Hawaiian/Other Pacific Islander ☐ Decline to Specify
Do you have an Advanced Directive/Living Will/Healthcare Surrogate? ☐ Yes ☐ No
Permanent Address: Seasonal Address
(Include Dates): Mailing Address:
Referring Physician ______________________ Primary Care Physician ________________________
Emergency Contact Name: ________________ Phone: (____)_____-_______ Relationship: __________
Allergies
(Please include medication allergies, environmental allergies & food allergies – if you require additional space please continue on page 4)
Allergies Reaction(s) Mild, Moderate or Severe
Please check here if a list of additionally allergies have been attached: ☐
Family Medical History
Mother Father Sister Brother
Paternal
Grandmother
Paternal
Grandfather
Maternal
Grandmother
Maternal
Grandfather
Age / Deceased
Prostate Cancer
Kidney Cancer
Bladder Cancer
Colon Cancer
Other Cancer(s)
Kidney Failure
Kidney or Bladder Stones
Polycystic Kidneys
Urinary Tract Infections
Interstitial Cystitis
Diabetes (Type I or II)
Cardiovascular Disease
Social History
Tobacco Use:
Are you a: ☐ Current tobacco user, ☐ Former tobacco user, ☐ Non-tobacco user, ☐Uses tobacco in other forms; specify: ____________
If you are a current tobacco user how long have you used tobacco? ______ If you are a former tobacco user when did you quit? _______
How often do you smoke? ☐ Daily ☐ Sometimes How many cigarettes a day do you smoke? ☐ 1ppd ☐ ½ppd ☐Less than ½ ppd
Second hand smoke exposure? ☐ Yes ☐ No If yes, please note: ☐ Frequently ☐ Sometimes ☐ Rarely
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Patient Name: _____________________________ D.O.B: ____/____/____
Tanglewood Professional Center Riverwalk Professional Park Lakewood Ranch MOB II
5809 21
st
Avenue West 200 3
rd
Avenue West, Suite 210 6310 Health Park Way, Suite 100
Bradenton, Fl 34209 Bradenton, Fl 34205 Lakewood Ranch, Fl 34202
Phone: (941) 792-0340 | Fax: (941) 794-2251 | Website: www.urology-partners.com | Email: info@urology-partners.com
Social History Continued
Alcohol Use:
Do you consume Alcohol? ☐ Y ☐ N What type of alcohol do you drink? ☐ Beer ☐ Wine ☐ Liquor
If yes, how often do you drink? ☐ Daily ☐ Weekly ☐ Socially ☐ Occasionally
Sexual History:
Are you sexually active? ☐ Y ☐ N
Do you currently have or do you have a history of a sexually transmitted infection? ☐ Y ☐ N
If yes, please specify: ☐ HPV ☐ Herpes ☐ HIV/AIDS ☐ Hepatitis (A / B / C) ☐ Gonorrhea ☐ Chlamydia
Other:
Exercise Habits: ☐ Daily ☐ Weekly ☐ Monthly | Dietary Habits: ☐ Specific Diet ☐ Overall Healthy ☐ None
Caffeine Habits: ☐ Daily ☐ Weekly ☐ Monthly ☐ Never
Do you take blood thinners? ☐ Y ☐ N If yes, specify (med./dose/freq.): _____________________________________
Review of Systems
(In the last six months, have you experienced any of the following symptoms?)
Constitutional Allergies Eyes Ears/Nose/Throat/Mouth
Easy Bruising Animal Double Vision Hearing Loss
Change in Appetite Environmental Changes in Vision Sinus Infections
Chills/Night Sweats Food Blurred Vision Difficulty Swallowing
Fatigue Seasonal Eye Pain Dry Mouth
Fever Itching/Redness Ringing/Painful Ears
Weight Loss/Gain
Endocrine Respiratory Cardiovascular Gastrointestinal
Tired/Sluggish Chronic Cough Swollen Extremities Abdominal Pain
Decreased Libido Shortness of Breath Painful Extremities Constipation
Cold Intolerance Wheezing Chest Pain Diarrhea
Excessive Thirst Palpitations Indigestion/Heartburn
Heat Intolerance Nausea/Vomiting
Hematologic Genitourinary Musculoskeletal Skin
Blood Clots Weak Stream Neck Pain/Stiffness Pigment Changes
Bleeding Problems Awaken to Urinate Back Pain/Stiffness Changing Moles
Recent Transfusion Leaking of Urine Joint Pain/Stiffness Open Wound(s)
Swollen Glands Burning Urination Muscle Cramps/Aches Change in Hair/Nails
Urgent Urination Sciatica Rash/Hives/Itching
Not Emptying Bladder Swollen Joints
Blood in Urine
Neurologic Psychiatric Women Only Men Only
Migraines Insomnia Prolapse of Bladder Difficulty w/ Erections
Fainting/Lightheadedness Depression Painful Intercourse Genital Pain/Swelling
Memory Loss Anxiety Vaginal Pain/Discharge Penile Discharge
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Patient Name: _____________________________ D.O.B: ____/____/____
Tanglewood Professional Center Riverwalk Professional Park Lakewood Ranch MOB II
5809 21
st
Avenue West 200 3
rd
Avenue West, Suite 210 6310 Health Park Way, Suite 100
Bradenton, Fl 34209 Bradenton, Fl 34205 Lakewood Ranch, Fl 34202
Phone: (941) 792-0340 | Fax: (941) 794-2251 | Website: www.urology-partners.com | Email: info@urology-partners.com
Medications
(If you require additional space please continue on page 4)
Please check here if medication list has been attached: ☐ Please list preferred Pharmacy: ______________________
P
Surgical History
(Please provide exact dates for surgical procedures, if known. If not please provide an approximation.)
Skin Cancer Removal Colon Resection Gall Bladder
Appendectomy PPM/ICD Implant Cardiac Stent
Thyroid Lung Surgery Hernia (Ing/Abd)
Hip (Right/Left) Knee (Right/Left) Back (C/T/L/S)
Hysterectomy Kidney Stone Removal Bladder Sling
Prostatectomy Nephrectomy (R/L)
Other: ______________________________________________________________________________________________
Past Medical History
(Please answer the following questions below about your personal past medical history.)
Cardiovascular
Heart Attack High Blood Pressure High Cholesterol Heart Valve Problems Irregular Heartbeat
Heart Murmur Deep Vein Thrombosis Anemia Bleeding Tendency Congestive Heart Failure
Endocrine
Diabetes Hyperthyroid Hypothyroid Gout
GI
Acid Reflux Irritable Bowels Peptic Ulcers Diverticulitis Diverticulosis
Crohn’s Colitis Gallstones Constipation Diarrhea
GU
Kidney Stones Bladder Stones Recurrent UTIs BPH Prostatitis
Hematuria Erectile Dysfunction Elevated PSA Incontinence Overactive Bladder
Hypogonadism Interstitial Cystitis Kidney Disease Other: __________________________________
EENT
Glaucoma Cataracts Vertigo Chronic Ear Infection
Musculoskeletal
Arthritis Chronic Back Pain Chronic Joint Pain Fibromyalgia
Neurologic
Stroke Chronic Headaches Parkinson’s Multiple Sclerosis Seizures
Polio Alzheimer’s/Dementia Spinal Cord Injury Spina bifida
Pulmonary
Emphysema Asthma Bronchitis COPD
Hematology/Oncology
Prostate Cancer Bladder Cancer Kidney Cancer Testicular Cancer Uterine Cancer
Ovarian Cancer Colorectal Cancer Lung Cancer Leukemia Lymphoma
Skin Cancer Other: _________________________________________________________________________
Medication Name Dosage Frequency
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Patient Name: _____________________________ D.O.B: ____/____/____
Tanglewood Professional Center Riverwalk Professional Park Lakewood Ranch MOB II
5809 21
st
Avenue West 200 3
rd
Avenue West, Suite 210 6310 Health Park Way, Suite 100
Bradenton, Fl 34209 Bradenton, Fl 34205 Lakewood Ranch, Fl 34202
Phone: (941) 792-0340 | Fax: (941) 794-2251 | Website: www.urology-partners.com | Email: info@urology-partners.com
Allergies
(Please include medication allergies, environmental allergies & food allergies)
Allergies Reaction(s) Mild, Moderate or Severe
Medications
Medication Name Dosage Frequency
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New Patient Intake Form Demographic Information

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Completed 30 April 2021

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