Tobacco Consumption (Circle One)

1. None

2. Less than 1 pack of cigarettes per week

3. Approximately 1/2 pack of cigarettes per day

4. Approximately 1 pack of cigarettes per day

Alcohol Consumption (Circle One)

1. None

2. 1-2 'drinks or beers per week

3. 4-5 drinks or beers per week

4. More than 6 Drinks or beers per week

Family Medical History: (Circle One)

1. Both parents living and well

2. One parent deceased; caused by: _________________________________

3. Both parents deceased; caused by:_________________________________

              and by: ______________________________ .

Is There a Family History of: (Circle)

1. Heart Attacks        Y    N                  Details If Yes: ___________________________

2. Diabetes                 Y     N                  Details If Yes: ___________________________

3. Urinary stones      Y     N                  Details If Yes: ___________________________

4. Kidney problems   Y    N                  Details If Yes: ___________________________

5. Prostate cancer    Y    N                  Details If Yes: ___________________________

6. Bladder cancer      Y    N                  Details If Yes: ___________________________

7. Kidney cancer        Y    N                  Details If Yes: ___________________________

8. Bladder problems Y    N                  Details If Yes: ___________________________

Patient Height: ______________ Patient Weight: ______________