NEW PATIENT HISTORY FORM
Date Referring Physician Your Last Name Your First Name
Date of Birth
GENDER - Male Female MARITAL STATUS - M S D W
SSN (optional) E-mail Street Address City
State Zip Home Phone
Cell Phone
Mailing Address if different from above
City
State
Zip
Employer
Name of Spouse/Significant Other
Phone for Spouse/Significant Other
Emergency Contact
Phone for Emergency Contact
INSURANCE INFORMATION
Insurance Name Type of Insurance - PPO POS Medicare
Insurance Address
Insurance Phone
Subscriber (if different from patient)
Relation to Patient
Policy Number
Group Number
BY CLICKING HERE I HEREBY AUTHORIZE MY INSURANCE TO MAKE PAYMENTS DIRECTLY TO KARYN S. EILBER, M.D. FOR ALL SURGICAL AND MEDICAL EXPENSE BENEFITS OTHERWISE PAYABLE TO ME FOR THIS PERIOD OF TREATMENT. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES NOT COVERED BY MY INSURANCE BENEFITS. I ALSO AUTHORIZE RELEASE OF MY RECORDS TO THE INSURANCE COMPANY FOR THE PURPOSE OF BILLING.
MEDICAL HISTORY
What is the main urologic issue that you would like to discuss?
Do you have any other urologic issues that you would like addressed?
Please list any medical conditions that you have (high blood pressure, diabetes, etc.)
1) 2) 3) 4) 5) 6) 7) 8) 9)
Please list any prior surgeries or procedures.
Date of Procedure
Please list any current medications/herbal supplements.
1) Dose 2) Dose 3) Dose 4) Dose 5) Dose
Please list any medications to which you are allergic.
1) Reaction 2) Reaction 3) Reaction 4) Reaction
For our female patients:
Number of pregnancies No. of deliveries
Vaginal or C-section Birth weights
Age at menopause Hormone replacement
Please list any serious illnesses in your immediate family.
1) Relative Illness 2) Relative Illness 3) Relative Illness 4) Relative Illness
What is your occupation?
On average, how many alcoholic beverages do you have in a week?
Did you ever smoke on a regular basis? YES NO If yes how many packs a day? Are you still smoking? YES NO
REVIEW OF SYSTEMS Do you have any problems related to the following? Please indicate Yes or No and explain any Yes answers in the space provided.
General: Fever................................YES NO Chills................................YES NO Weight Loss......................YES NO Weight Gain.....................YES NO Use this space for Detailing YES answers or for any additional information we should know.
Eyes: Blurred Vision ..................YES NO Glaucoma..........................YES NO Use this space for Detailing YES answers or for any additional information we should know.
Ears/Nose/Throat: Difficulty hearing..............YES NO Sinus Problems..................YES NO Nasal Bleeding..................YES NO Use this space for Detailing YES answers or for any additional information we should know.
Respiratory: Shortness of breath............YES NO Cronic Cough....................YES NO Use this space for Detailing YES answers or for any additional information we should know.
Cardiovascular: Chest pain.........................YES NO Heart attack.......................YES NO Leg swelling......................YES NO
Genitourinary: Frequent urination.............YES NO If YES, how often? Wake to urinate.................YES NO If YES, how many times? Slow stream......................YES NO Push to urinate..................YES NO Retaining urine.................YES NO Painful urination...............YES NO Urinary tract infections.....YES NO Blood in urine...................YES NO Incontinence.....................YES NO Number of pads if any? Sexual activity..................YES NO Low libido........................YES NO MEN - Erectile dysfunction..........YES NO
Gastrointestinal: Abdominal pain................YES NO Nausea/vomiting...............YES NO Chronic constipation.........YES NO Diarrhea............................YES NO
Musculoskeletal: Chronic back pain.............YES NO Sciatica..............................YES NO Back surgery.....................YES NO Use this space for Detailing YES answers or for any additional information we should know.
Neurological: Migraines..........................YES NO Dizzy spells.......................YES NO Numbness/tingling............YES NO Weakness..........................YES NO
Integumentary: Skin rash...........................YES NO Skin lesions.......................YES NO Use this space for Detailing YES answers or for any additional information we should know.
Allergic/Immunologic: Hay fever.........................YES NO Food allergies...................YES NO Use this space for Detailing YES answers or for any additional information we should know.
Hematologic: Blood clotting disorder....YES NO Anemia............................YES NO Swollen glands................YES NO Easy bruising...................YES NO
Endocrine: Excessive thirst................YES NO Too hot/cold....................YES NO Tired/sluggish..................YES NO Use this space for Detailing YES answers or for any additional information we should know.
Psychological: Depression......................YES NO Anxiety...........................YES NO Substance abuse..............YES NO
DO YOU EXPERIENCE, AND IF SO, HOW MUCH ARE YOU BOTHERED BY: Please indicate one: 0 – Not at all, 1 – Slightly, 2 – Moderately, 3- Greatly 0 1 2 3 Frequent urination? 0 1 2 3 Urine leakage related to the feeling of urgency? 0 1 2 3 Urine leakage related to physical activity, coughing, or sneezing? 0 1 2 3 Small amounts of urine leakage (drops)? 0 1 2 3 Difficulty emptying your bladder? 0 1 2 3 Pain or discomfort in the lower abdomen/genital area? HAS URINE LEAKAGE OR PROLAPSE AFFECTED YOUR: Please indicate one: 0 – Not at all, 1 – Slightly, 2 – Moderately, 3- Greatly 0 1 2 3 Ability to do household chores? 0 1 2 3 Physical recreation such as walking, swimming, or other exercise? 0 1 2 3 Entertainment activities (movies, concerts, etc)? 0 1 2 3 Ability to travel by car or bus more than 30 minutes from home? 0 1 2 3 Participation in social activities outside your home? 0 1 2 3 Emotional health (nervousness, depression, etc)? 0 1 2 3 Feeling frustrated?