Microsoft word - tucc intake form-with highlights

THE UROLOGY CENTER OF COLORADO
Please Print

____________________________________________________________________________________________________
Patient Name Date of Birth
____________________________________________________________________________________________________ Referring Physician Reason For Visit
YOUR MEDICAL HISTORY: Circle if yes:
Cardiac:
Musculoskeletal: Total Joint Replacement* Any Cancer: ________________________________________________________________ Any Radiation: No Yes: Site on body _________________________________________
Allergies: No Circle if yes:
Penicillin Ampicillin Sulfa Bactrim Macrodantin Levaquin Cipro Iodine Tape Latex
Other: _____________________________________________________________________
P PRESCRIBED MEDICATIONS
SUPPLEMENTS, HERBALS, ETC
Name of Medication
Strength
When you take it
Name of Item
Strength
When you take it
DO YOU TAKE ANTIBIOTICS PRIOR TO PROCEDURES? _____YES ______NO
If yes, what is the name of the antibiotic? _______________________________________

PLEASE TURN PAGE OVER

SURGERIES: Type of surgery and approximate date:

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
GENITURINARY HISTORY: No Please circle if yes
Kidney Cancer
Do you leak urine when you cough or exercise? Do you leak urine when you feel an urge to urinate but cannot get to the bathroom in time? ____________ Do you have problems achieving or maintaining an erection?
FAMILY MEDICAL HISTORY: Relationship
Cancer – Kidney / Bladder / Prostate _____yes _____no ____________________
Kidney problems / stones _____yes _____no ____________________
Blood pressure problems _____yes _____no ____________________
Bleeding problems _____yes _____no ____________________
Diabetes _____yes _____no ____________________
Asthma / Breathing problems _____yes _____no ____________________
Reaction to anesthesia _____yes _____no ____________________
Cardiac problems _____yes _____no ____________________
SOCIAL HISTORY:
Do you use tobacco?____yes____no If yes, packs per day? _____________________
Have stopped using tobacco? ____yes _____no If yes, how long did you smoke _______
Do you use alcohol? ____yes ____no If yes, how often and how much _____________
Do you have a history of sexually transmitted diseases? ___yes ___no
Do you use recreational drugs? _____yes ______ no What kind? ____________________
Retired _____, Working ______, What is / was your occupation? _______
Married / Single / Other ___________
# of Children ____________ # Pregnancies ______ Currently pregnant ___yes ___no
Parent’s current age, if alive:
Mother______________ Father _______________ If deceased, age & cause of death: Mother______________ Father_______________

REVIEW OF SYMPTOMS: No
Other______________________________________________________ Physician’s initial__________ Date __________ Form updated 10/10

Source: http://www.tucc.com/UserFiles/file/TUCC%20Intake%20form-with%20highlights(1).pdf