400 Shadowline Dr, Suite 103-104 I Boone, NC 28607 828-264-5150 I fax 828-265-3611 apprhs.org/urology Thank you for choosing Boone Urology Center as your healthcare provider. The physicians at Boone Urology Center combine skill and experience in the compassionate treatment of your urological condition. We make every effort to make your treatment experience as simple as possible for you. Urology is the diagnosis, treatment and surgery of problems relating to the genito-urinary system. These problems include urologic cancer, impotence, urinary tract infection, kidney stones, and urinary incontinence. Our trained medical staff is available to answer your questions concerning medication, treatment, insurance, and billing during regular office hours (8:00 a.m. to 5:00 p.m. weekdays). Conditions and services offered: enlarged prostate, erectile dysfunction, incontinence, kidney stones and vasectomy. Urology services are available at Jefferson Specialty Clinic (West Jefferson, NC). Call (828) 264-5150 to schedule an appointment. Our office is available to you by phone from 8:00 a.m. - 5:00 p.m. Monday - Friday. If you have any questions, please call our office manager at (828)264-5150. _________________________________________ This new patient information packet includes directions to has an appointment with our office and contact information for you to keep for your _________________________________________ records. The terms of our financial agreement and notice of ☐ Mon. ☐ Tues. ☐ Wed. ☐ Thurs. ☐ Fri. privacy practices are available in our office. Additionally, we’ve enclosed forms you will need to complete and bring with _________________________date _____________a.m./p.m. ☐ Boone, NC ☐ West Jefferson, NC you to your first visit. 194 To reschedule321 your appointment, please call 4(828)21 264-5150. BOONE NEW PATIENT CHECKLIST: B lo 221 Boone Urology w For your first appointment please arrive in g R o S c t k a 400 Shadowline, t R e 15 minutes early and bring Tractor Supply Co. d Meadow Creek Fa Shopping Center rm Suite 103-104 BUS Rd BUS Faith 221 the following: 221 Fellowship Boone Jeerson Specialty 321 r D Clinic dowli n e O'Reilly Sha De 105 e ☐ Insurance Card Auto Parts rfield Cardinal Rd Lanes ☐ Pharmacy Information 968 Hwy 221 ☐ Medical Records Business Mt Jefferson Rd Watauga ☐ Payment West Jefferson Medical Center ☐ Current Medications ASHE ☐ Questions for doctor COUNTY ☐ Completed forms 221 ☐ Information from previous doctor NORTH 11198 05/11/20 Patient Name_________________________________ Date of Birth_________________________________ Phone Number________________________________ Patient Registration Please Fill in or Affix a Patient Label Patient Name: First M/I Last Date of Birth: ____/____/______ Gender: Male Female Social Security #: _____-_____-_____ Marital Status: Married Single Divorced Separated Widowed Life Partner Mailing Address: Street- City- State- Zip Code- Primary Phone #: Cell Home Secondary Phone #: Cell Home Work Phone #: Employer/Occupation: E-mail: Emergency Contact: Relationship to patient: Ph #: I consent to Appalachian Regional Medical Associates (“ARMA”) or its representatives: calling my phone and leaving a message texting me (message and data rates may apply) e-mailing me about balances due, financial assistance, appointments, pre-registration, lab results, and other healthcare information. Methods of contact may include pre-recorded voice messages and the use of automatic dialing services. What is your ethnicity? Hispanic or Latino Not Hispanic or Latino Select one or more races to indicate what you consider yourself to be: Asian White American Indian or Alaskan Native Black or African American Native Hawaiian or other Pacific Islander Other: ___________________________ Preferred language? English Spanish Other: ___________________________ How did you hear about us? Billboards Doctor Friends/Family Magazine Newspaper Social Media Radio TV ARHS Website Other _______________________ If patient is a minor please print Guardian Name: First: ________________________________ M/I: ________ Last: ___________________________________________ If patient has a guarantor (someone else responsible for the bill) please provider information below: Patient’s relationship to Guarantor: __________________________________________________________________ Guarantor’s Name: First: __________________________________M/I:_________________Last:_________________ Mailing Address: Street- ______________________________________________________________________ City-_______________________________________________________State-_______________ Zip-______________ Date of Birth: ____/____/_____ Social Security #: ______-_____-_______ Phone #: ________________________ Employer: ____________________________________________ Employer Phone #: __________________________ Signature of Patient/ Legal Representative Date: Time: Name of Patient/ Legal Representative (Please Print) Relationship of Legal Representative Page 1 of 1 Effective Date: 04/20/2018 Revised Date: 01/12/2021 Form Number: 11332 Patient Name_________________________________ Date of Birth_________________________________ Phone Number________________________________ Please Fill in or Affix a Patient Label Boone Urology Center Patient Information Review of Systems Are you currently having problems related to the following? Please check your answer. Constitutional: Yes No Gastrointestinal: Yes No Respiratory: Yes No Fever Abdominal pain Wheezing Chills Nausea Cough Vomiting Shortness of breath Indigestion Coughing up blood Endocrine: Diarrhea Sleep Apnea Weight loss Constipation Weight gain Excessive gas Musculoskeletal: Excessive thirst Loss of appetite Joint pain Fatigue Blood in stool Hemorrhoids Psychological: HEENT: Neurological: Stress Ear infection Tremors Depression Hearing loss Dizziness Sore throat Headache Sinusitis Other brain disorder Cardiovascular: ________________ Chest pain Diminished vision Ankle swelling Skin: Irregular heart beat Rash Heart murmur Itching Excessive bleeding Other: __________________ __________________ Patient History: Date of Yes No Date of Yes No Diagnosis Diagnosis ___________ Cancer (type) ___________ Phlebitis ___________ Sexually Transmitted Disease ___________ Stroke ___________ Tuberculosis ___________ Peptic ulcer disease ___________ Diabetes ___________ Gallbladder trouble ___________ High cholesterol ___________ Colitis ___________ Hormone imbalance ___________ Hepatitis (type) ___________ Thyroid problem ___________ Multiple Sclerosis ___________ Anemia ___________ Alcoholism ___________ Glaucoma ___________ Arthritis ___________ Emphysema ___________ Gout ___________ Pneumonia ___________ Injury or trauma ___________ Bronchitis ___________ Fracture (type) ___________ Asthma ___________ Migraine ___________ High Blood Pressure ___________ Seizures ___________ Rheumatic fever ___________ Other ___________ Heart attack ___________ ___________ Hiatal Hernia ___________ Mumps Page 1 of 3 Effective Date: 09/14/2015 Revised Date: 04/12 /2016 Form Number: 11010 Patient Name_________________________________ Date of Birth_________________________________ Phone Number________________________________ Please Fill in or Affix a Patient Label Boone Urology Center Patient Information Family History: Personal Data: Has anyone in your family had any of the following? If yes, list Height ______ft ______in who (mom, sister, uncle). How long did it take you to get here? ______________________ Yes No With whom do you live? ________________________________ Diabetes Yes No High blood pressure Do you perform strenuous activity? Please explain: Kidney stones __________________________________________ Kidney disease Are you on a special diet? Please explain: Cancer (type) __________________________________________ Prostate cancer Habits: Yes No Do you smoke? If yes, how much? ____________________________________________ Did you smoke in the past? If yes, when did you quit last? ___________________________________ Do you drink alcohol? If yes, how much? ____________________________________________ Occupation: ______________________________ Education Level: _____________________________________________ Women Only: Yes No Yes No Abnormal vaginal bleeding Last menstrual period, date: _______________ _____ Number of pregnancies _____ Number of live births Operations: Date Procedure Where Surgeon Yes No Pacemaker Date:________________ Hospitalizations: Date Reason Where Doctor Page 2 of 3 Effective Date: 09/14/2015 Revised Date: 04/12 /2016 Form Number: 11010 Patient Name_________________________________ Date of Birth_________________________________ Phone Number________________________________ Please Fill in or Affix a Patient Label Boone Urology Center Patient Information Medications: Medication Name Dose (mg, grams, etc) How many times a day Reason for Medication Yes No Do you take Aspirin? Dose: ______________________ Medication Allergies & Reactions: Allergies to Other Agents (foods, materials, ect.) & Reactions: Yes No Do you have a Latex Allergy? _________________________________________________________________________ _____________ _____________ Patient Signature Date Time _________________________________________________________________________ _____________ _____________ Patient’s Guardian Signature Date Time _________________________________________________________________________ Relationship _________________________________________________________________________ _____________ _____________ Reviewed by Date Time _________________________________________________________________________