New Patient Questionnaire BP: ______Pulse: ______Temp: ______Weight: ______Height: ______Pain: ______Fatigue: ______

Patient’s Name: ______Gender: M F Spouse’s Name: ______Email:______Today’s Date: ______Date of Birth: ______Age: ______Ethnicity:______Race:______Preferred Language:______Reason for Today’s Visit: ______Primary Care Physician: ______Urologist: ______Advance Health Care Directives? (Living Will, Power of Attorney) Yes__ No__ Copy Filed with (name)______Phone______

Medical History: Have you ever had any of these diagnoses (Circle Y or N): Previous cancer? Y N Horseshoe kidney? Y N High blood pressure? Y N Thyroid disease? Y N Heart disease? Y N Lupus or Scleroderma? Y N Pacemaker? Y N Inflammatory bowel disease? Y N Diabetes? Y N Diverticulitis? Y N Emphysema or COPD? Y N Hemorroids? Y N Kidney loss/dysfunction? Y N Enlarged Prostate? Y N

Previous radiation therapy? Y N If so, to what part of the body? ______At what facility? ______Dates? ______Previous or current chemotherapy? Y N If yes, what facility?______Dates?______

Have you ever been screened for colorectal cancer? Y N Type of test? (please circle) Fecal occult blood test Flexible sigmoidoscopy Colonoscopy Location and date of colorectal exam? ______

Previous Surgeries: Type of Operation Approximate Date Type of Operation Approximate Date ______Other illnesses and hospitalizations: ______

Family History: Father: Type of Cancer? ______Age Diagnosed ______(Circle) Living/Deceased Age: ______Mother: Type of Cancer? ______Age Diagnosed ______(Circle) Living/Deceased Age: ______Sibling: Type of Cancer? ______Age Diagnosed ______(Circle) Living/Deceased Age: ______Sibling: Type of Cancer? ______Age Diagnosed ______(Circle) Living/Deceased Age: ______Other: ______Other: ______

New Patient Questionnaire

Social History: On average, how many caffeinated beverages such as coffee, soda, or tea do you have per day? ______Do you drink alcohol? Y N If yes, average number of drink per day: ______Do you have a personal history of alcoholism? Y N Do you have a personal history of recreational drug use? Y N How many times in the past year have you had 5 or more drinks in a day? ______Have you ever smoked cigarettes? Y N If yes, year began: ______Year stopped: ______Average packs per day: ______List other tobacco products used: ______

How many times per week do you exercise? ______Type of exercise:______Minutes per exercise session: ______Current occupation: ______# years: ______Previous occupation: ______# years: _____ Are you a Vietnam Vet? Y N Marital Status: ______# of Children: ______

REVIEW OF SYSTEMS: (Check box to indicate YES)

Constitutional Gastrointestinal Genitourinary Fever Nausea/Vomiting Frequency/Urgency Chills Constipation/Diarrhea Painful Urination Weight Loss Blood in Stools Urine Leakage Fatigue Hemorrhoids Blood in Urine Night Sweats Heartburn Nocturia Appetite (circle one) Good/Fair/Poor Wear a Pad Cardiovascular Ears/Nose/Mouth/Throat Neurological Heart Murmur HOH/Hearing Aid Dizziness Chest Pain Sinus Drainage Tremors Abnormal Heart Rate Seasonal Allergies Speech Difficulty Fainting Spells Nosebleeds Headaches Edema-Feet/Ankles Difficulty Swallowing Respiratory Psychiatric Eyes Shortness of Breath Anxiety Glasses/Contacts Wheezing/Asthma Depression Double Vision Productive Cough Memory Loss Glaucoma Confusion Cataracts Skin Musculoskeletal Endocrinological Rash/Psoriasis Arthritis/Joint Pain Thyroid Problems Open Wounds Gout Hematological Anemia Excess Bruise/Bleed