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BERTINI/HARRIS UROLOGY Last Name: ___________________________ First Name: _____________________________ MI: ____ DOB: ___ /___ /___ Age: _______ Today’s Date: ___ / ___ / ____ Why are you here to see the Doctor? _____________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Drug Allergies (List any allergies you have to any medications. ) _______________________________________ ___________________________________________________________________________________________ What medications are you currently taking? If none, write "none". _____________________________________ __________________________________________________________________________________________ Past Medical Diagnoses: (Circle one: Y=yes, N=no, U=unknown) Diabetes Y N U Bleed Problems Y N U Glaucoma Y N U Heart Attack Y N U Arthritis Y N U Asthma Y N U Stroke Y N U AIDS Y N U Emphysema Y N U Angina/Chest Pain Y N U HIV Infection Y N U Ulcers Y N U High blood pressure Y N U Kidney failure Y N U Colitis Y N U Heart Failure Y N U Urinary stones Y N U Cancer Y N U Hepatitis Y N U Bladder leakage Y N U - If Yes, what type: _________________ Yellow Jaundice Y N U Voiding problems Y N U Operations : __________________________________________________________ Year: ___________ __________________________________________________________ Year: ___________ __________________________________________________________ Year: ___________ Urologic Problems: _____________________________________________________ Year: ___________ _____________________________________________________ Year: ___________ _____________________________________________________ Year: ___________ |