Texoma Urology Center

TEXOMA UROLOGY CENTER 5500 Kell West Blvd., Suite 200 & 300 * Wichita Falls, TX 76310 Phone (940) 689-UROL (8765) Fax (940) 689-8769

Phillip E. Dowd, M.D. J. Stephen Dryden, M.D. R. Kyle King, M.D. Michael W. Toulan, M.D. PATIENT HISTORY FORM

Today’s Date______/______/______

Last Name______First Name______Initial______

Date of Birth______

Reason for today’s visit______

______

Location of Problem ______Abdomen ______Kidney ______Prostate ______Bladder

______Other When did you first notice this problem?______

MEDICATION LIST

Please list all medications you are now taking including over the counter medications. ( If you are providing a separate list, please check here ______)

Medication______Strength______How often do you take?______

MEDICINE ALLERGIES

Are you allergic to iodine or dyes? ______yes ______no

Please list all medications you are allergic to. ______

______

Please complete back of form…….. Texoma Urology Center Patient History Form Page 2 Patient: ______

PAST MEDICAL AND SOCIAL HISTORY Past Surgeries Year Illnesses Requiring Hospitalization Year ______

______

Do you smoke? Yes_____ No_____ If yes, how much?______# years___ Year Quit_____

Do you drink? Yes_____ No_____ If yes, how much?______

Do you have any bleeding tendencies? Yes_____ No_____ Explain______Have you ever had a blood or plasma transfusion? _____Yes _____ No If yes, when______FAMILY HISTORY Please check and list any family history of serious illnesses or serious medical problems:

Diabetes………____ Who? ______Parkinson’s Disease_____ Who?______Cancer………...____ Who? ______Stroke………………. _____ Who?______Heart Disease..____ Who? ______Other______Who?______Other______Who?______REVIEW OF SYMPTOMS Have you been diagnosed with any serious illness or medical problem? ____Yes ____ No

Please explain:______

Are you diabetic? ____Yes ____No Additional comments:______

Please check symptoms you currently have: HEAD, NOSE AND THROAT RESPIRATORY CARDIOVASCULAR ____Recurrent Headaches ____Shortness of Breath ____Plebitis ____Leg Cramps

Shortness of Breath

Yes No

Phlebitis Yes No Leg Cramps ____Sinus Problems ____Chronic or Frequent Cough ____Easy Bruising ____Swelling Hands ____Chronic or Frequent Cough ____ Asthma ____Mitral Valve Prolapse ____Swelling Feet ____Ear Problems ____Emphysema ____Blurred Vision ____Swelling Ankles ____Eye Problems ____Wheezing ____Fainting Spells ____Tingling Hands ____Enlarged Glands ____Coughed up blood ____Chest Pain ____Tingling Feet ____Recurrent Nosebleeds ____Other______Heart Problems ____ Weakness/Hands ____Hearing Problems ____Other______Anemia ____Weakness/Feet ____Difficulty Swallowing ____Other______Dizziness Other ______

GASTRO-INTESTINAL GENITOURINARY ____Nausea or Vomiting ____Colitis or other Bowel Disease ____Pain on Urination ____Vomited Blood ____Hemorrhoids or Rectal Disease ____Any Blood in Urine ____Abdominal Cramping ____Change in Bowel Movements ____Problems Urinating ____Peptic Ulcer Disease ____Rectal Pain ____Kidney Problems (explain)______Chronic Indigestion ____Rectal Bleeding ____Prostate Problems (explain)______Kidney Stone(s) ____Previou Prostate Surgery______

FEMALE Last Menstrual Period ______Menopause? ___Yes ___No Tubal Ligation? ____Yes ___No Year ______Have you had any of the following tests within the last 6 months?

WHERE? WHEN? ____ X-Ray – Kidney ______Cat Scan – Kidney / Abdomen ______IVP (X-Ray with intravenous dye)______PSA (Prostate Blood Test) ______