Wichita Urology Group, P.A. MEDICAL HISTORY FORM

Patient Name______DOB______Age______

Family Doctor______City______Referring Doctor______

Other Doctors Caring For You______

Reason for Today’s Visit/Chief Complaint ______

PATIENT PAST MEDICAL HISTORY **Please place a checkmark next to what applies to you**

Heart Disease Endocrine Disease Genitourinary Disease _____Hypertension (high blood pressure) _____Diabetes Type 1 or 2 (please select) _____Kidney disease/failure _____High Cholesterol _____Thyroid disease (hyper or hypo) _____Kidney Stones/Bladder stones _____Heart Attack/ AMI _____Hypogonadism / Low Testosterone _____Urinary Tract Infections _____Blood thinners Cancer _____Enlarged prostate (BPH) (Coumadin, Plavix, aspirin, _____Breast _____Urethral Stricture Pradaxa, fish oil) _____Lung _____Prostate infection _____Congestive Heart Failure _____Ovarian/Uterine/Cervical _____Urinary leakage _____Irregular Heartbeat/A-fib _____Colon _____Interstitial Cystitis Vascular Disease _____Lymphoma/Leukemia _____Duplication of Ureter _____Stroke/TIA _____Radiation Therapy Infectious Disease _____Deep Venous Thrombosis (Clot in Legs) _____Chemotherapy _____Genital warts _____Clot in lungs Urologic Cancer _____Herpes oral / genital _____Aneursym _____Prostate (Adenocarcinoma) _____HIV _____Peripheral Vascular Disease/Aneurism _____Bladder Cancer Transplant Status Eyes _____Kidney / Renal cell Cancer _____Transplant Organ:______Glaucoma(wide angle/ narrow) _____Ureter Cancer Gynecologic/Birth History Lung Disease _____Testis Cancer _____Endometriosis _____Asthma _____Penile cancer _____Falling Bladder (Cystocele) _____COPD Neurologic/Orthopedic Disease _____Falling Rectum (Rectocele) GI/Liver Disease _____Parkinson’s Disease Psychologic Disease _____Gastroesophageal Reflux Disease/ ulcer _____Seizure Disorder _____Bipolar _____Hepatitis B or C (please select) _____Spinal Cord Injury/Paralysis _____Anxiety Disorder _____Liver disease/failure _____Spina Bifida _____Depression _____ Crohn’s/ Ulcerative Colitis (please _____ Multiple Sclerosis _____Schizophrenia select) _____Chronic Back/Spine Pain Other: Hematologic Disease Rheumatologic/Bone Disease _____Bleeding/Clotting Disorder _____Fibromyalgia

SURGICAL HISTORY

General Surgery Cardiothoracic Surgery Neuro/Head/Neck Surgery _____Appendectomy _____Heart Stent/Angioplasty _____Tonsillectomy _____Hernia Repair _____Heart Bypass Orthopedic Surgery _____ Inguinal / Umbilical / Incision Gynecologic Surgery _____Hip Replacement _____Cholecystectomy (Gall Bladder) _____C-Section _____Knee Replacement _____Colon _____Hysterectomy Other / unlisted _____Any Open Abdominal Surgery Cancer Surgery _____Type:______Type :______

Patient name______DOB ______

UROLOGIC SURGICAL HISTORY

Genitourinary Cysto/Stone GU MALE GU MALE _____Extracorporeal Shockwave _____Male Sling _____Prostatectomy Lithotripsy (ESWL) _____Orchiopexy Open / robotic _____Ureteroscopy/laser stone _____Orchiectomy _____Artificial Urinary Sphincter _____Percutaneous Stone Removal (PCNL) _____Hydrocele Repair _____Inflatable Penile Prosthesis _____Hydrodistention of Bladder _____Spermatocele Repair _____Bladder tumor resection (TURBT) _____Varicocele Repair Genitourinary Major _____Treatment of genital warts GU Female _____Kidney removal _____ Prostate Biopsy _____TVT / urethral / Vaginal Sling _____Partial Nephrectomy _____Vasectomy _____Cystocele Repair (bladder lift) _____Nephroureterectomy _____Vasectomy Reversal _____Pyeloplasty / UPJ repair _____TURP (prostate resection) _____Removal of urinary bladder

SOCIAL HISTORY

Smoking Alcohol Occupation Never / Occasional Rare / Socially / Daily Retired / Part time / Full Time Active Smoker for ______Years Amount ______Type of Work______Packs Per Day ______Illicit Drug Use Marital Status Quit ______( weeks/ months/ years ago) Never / Quit / Active Marital status ______Type of drug (s) Number of children______Number of Biological Children_____

Father's Father's Mother's Mother's Diagnosis Father Mother Brother Sister Father Mother Father Mother Prostate Cancer Y N Kidney Cancer Y N Bladder Cancer Y N Urinary Stones Y N