Male New Patient Forms

~~,ListNEW PATIENT QUESTIONNAIREDATE OF BIRTHMALETODAY'S DATE~j~i~~~c~t.~(jridmdri"""C;d@"t~tu~SURGERIES! HOSPITAUZA TIONS '"all your major surgeries and hospitalizations","C',."'" " , "" ,,' " ',' " "'" --"".:",:";;;,...,c,;

FAMILY HISTORY List family members who have had anyof the following medical problems:.. ..... .. . ..... ..... .. .MEDICAL PROBLEM FAMILY MEMBER MEDICAL PROBLEM FAMILY MEMBERAlcoholism (V19.8) Hardeningof Arteries (V17.4)Allergies (V19.6) Heart Attack (V17.3)Anemia (V18.2) Heart Disease (V17.4)Asthma (V17.5) Hepatitis (V18.8)Birth Defects (V19.5) Hypertension (V17.4)Bleeding Problems (V18.3) HIV / AIDS (V18.8)Breast Cancer (V16.3) Kidney Disease (V18.69)Cancer (list Type) Leukemia (V16.6)Deafness (V19.2) liver Disease (V19.8)Diabetes Mellitus (V18.0) Lung Disease (V17.6)Emphysema/COPD (V19.8) Mental Problems (V17.0)Epilepsy (V17.2) Migraine headaches (V17.2)Genetic Disorder (V19.5) Muscle Disorders (V17.8)Glaucoma (V19.1) Stroke (V17.1)Other Significant Medical Problems in the Family:0 1 2 3 4 50 1 2 3 4 5Urgency:. Overthe past monthneed to urinate again Jess thim 2 hours after youunnating? .OvertbepastmonthHol1>'oftenhilVe you found it diffi.cUIt to \>Ostpolle urination?VVeakStream: . Overthepastmol1thHow:Oftenhav~you had. a weak urine stream?Straining:.Overthe paSt monthHow often did you had to push or strain to begin urination?Nocturia: . Ona typicalnightHow often do you get up to. urinate?If you were to spend the. rest of your life with youruiinarycondition just the way it is now, how wouldyou feel about that?0 1 2 3 4 50 1 2 3 4 50 1 2 3 4 50 1 2 3 4 5NONE .1TIME...... 2 TIMES 3TIMES. 4 TIMES 5 ormore0 1 2 3 4 5Delighted Pleased Mostly qlJlly . MosysatisfiedSatisfiedDissatifiedUnhappyDissatiSfied0 1 2 3 4 5

HEAL TH RISK ASSESSMENTCHI~~kP:ii)('---'-MEAsLESHEPATITISHEPA TlTISBFLUAFarm SiloToxicChemicalsCollegeMastersYears of ServiceAsbestosSandblastingDoctorateTechnical SchoolSpecialtyMarriedDivorcedWidowerSingleLive with PartnerBirdsRadioactive MaterialsVocational SchoolOther,Do you go to VA Clinic?SPOUSEIPARiNER. TOSAbo . Never used I-- Cigarettes AgeStarted Methodstried to quit:i-- Used in past, but quit I-- Cigars Age Stopped(CIiGkClII '--- Still Use Itf--- Pipe Packs/amount per daythafCipply)Ready to QuitSnuff/Chew., .,' Never a drinkerf---3 or more drinks daily AlcoholicI--ALCOHOLI--1-5 Drinks per YearI-- Drink heavy on weekends only Recovered Alcoholic(c::hGK11 f---- 1-2 Drinks per Month I-- Heavy drinker all week Sobriety Date:thCitlilPPfY) I-- 1-2 Drinks weekly f-- Onelboth parents are alcoholics I attend AA1-2 Drinks Daily I need helpIL4eGAL I--- Never used drugs - Marijuana - I needhelpDRUGUSe f---- 1-5 times per year - Methamphetamine - [have useddrugs,butquitf---- 1-2 times per month - Crack or Cocaine I attend NA(c:hGKClIIth?tpp\Y) f---- 1-2 times per week - Intravenous(IV) DrugsOther drugs I have used1-2 times per day I have shared needles in the pastCholesterol: I eat plenty of servings of fresh fruits and vegetables each dayNUTRITION HDL I need dietary counseling n I eat too much fat. ANP.. LDLEXERCISESpecial DietTriglyceridesAmount of Caffeinated DrinkslDay (coffee, tea, softdrinks, etc)'.Date Form of Exercise.Do you have a parent, sibling,or child with a history of colon- yeS If yes, who?COLON " cancer or colon polyps? NOCANCER Ever had colon cancerscreening by sigmoidoscopy -YES If yes, which doctor did this procedure?or colonoscopy?NOSI;XUA'LACTIVITY IFS!3XUALLYACrt\fEP'lil IF>';1 PARrt,jEI!HA$r'(EA.J'{ SEXUALLY NSMIT1"EPDISEASES- Virgin - Long-term monogamous situation - Always use condoms -- Chlamydia- Sexually Active- 2-5 partners in last year - Sometimes use condoms Gonorrheac--SEX.IJAL Sexually Active in past, - 6-10 partners in last year -Never use condoms SyphilisHISTORY butnotfor-I--yearsMore than 10 partners in last year Genital Warts. ..E!I,.PPP'TE$T$f:()J'{f,fI\l,fI£:PAI1T!$I;I,'A....[)H£:AJ1"I1$ie. ' . OtHEftCONCEftNS HIVHepatitisr---i I want have to been betested H ,I .My wantmy partnerpartnertested has been testedHepatitis_c;-B'.".IMMUNIZATION HISTORYI have had the chicken poxvaccine I have had chicken pox I have had shinglesI JI was born before 1957 (no booster needed)I have never had Hepatitis A or the vaccineI have never had Hepatitis B or the vaccineI get flu shots every yearNAMEI was bom after 1956 and I'veI had the Measles or MMR booster)I J 0 never had a booster shotI had Hepatitis A shotsI had Hepatitis A inr--""'"I had Hepatitis B shotsI do not get flu shots becauser--I had Hepatitis B inPNEUMONIAI have had the PneumovaxvaccineLYMETETANUSHigh exposure to ticks Interested in Lyme Disease VaccinationI---My last tetanus shot was I have never had a tetanus shot

;eYES..EA~S..QSEISINUSMQ.UTH I Tl-tRQATGlasses Blurry Vision CataractsContacts Blind Spots Eye Drainage Dryness. ConndWffisI==J . Redness Night BlindnessExcessive Tearing Color Blind Double Vision GlaucomaHearing Loss Ear Infections Noises in the Ear TinnitusL-J Ear WaxEar Pain Ear Drainage Motion Sickness VertigoSinus Pain Sinus Infection Nasal Polyps Nasal Drainage L-J Allergic RhinitisSinus Pressure Nose Bleeds Loss of Smell Nasal CongestionSore Tongue Bleeding Gums Hoarseness DenturesSore Throat Mouth Ulcers Thrush Change in TasteCavities Tooth Pain S1rep ThroatHEARTLUNGSGASTROJNTESTINALU.RI"ARYNeRVOUS. .MUSCULOSKELETAL. .ENDOCRiNE. \,'. - .MENTAL. HEALTHBLOOD;LYMPHChest Pain Rheumatic Fever Hair Loss on Legs Shortness of breath when lying downHeart Attack Heart Murmur Palpitations Need antibiotics before dental workPoor Circulation Pacemaker Heart Pounding Fingers turn blue, white, or red. SpiderVeins Uloers on legs Swelling of feet Wake up short of breath at nightIrregular Heartbeat Blood Clots HighBloodPressure Pain in legs after walkingChronic Cough Wheezing Smoker Cough up sputum I phlegmShort of breath Cough up blood History of Pleurisy Shortness of breath with mild exerciseAsthma Use Home Oxygen History of COPD Shortness of breath when climbing stairsNausea Blood in Stool Vomiting Blood Liver Problems Abdominal PainVomiting Dark Stool Color Trouble Swallowing UloersDiarrhea Appetite Loss Hemorrhoids Change in Bowel HabitsConstipation Bloating Pancreatitis Gall Bladder ProblemsBed Wetting Frequent Urination at Night DifficultyStarting Urine FlowLeaking Urine Pain/Burning with Urination DifficultyStopping Urine FlowKidney Stones Inability to Hold Urine Urine, Bladder, Kidney InfectionSeizures Numbness Fainting Spells Weakness of Arm or LegParalysis Polio Dizzy Spells Temporary BlindnessMeningitis Headaches Stroke Other:Painful JointsMuscle PainsArthritis Carpal Tunnel H Swollen Back PainJointsH Gout Herniated DiskL-J BoneluriesCold Intoleranoe Thyroid Problems Diabetes Excess Thirst I I Exoess UrineHeat Intoleranoe Parathyroid Hair LossIThinning Exoess HungerDepressed Poor Conoentration Cry too much Memory Problems Appetite ProblemsSuicidal Thoughts Excess Worry Excess Anger Sleep Problems UnhappylMoodyAnemia n Easy Bleeding n Easy Bruising n Swollen or painful lymph nodesOur office wants to make any accommodations necessary to meet your specific needs. If you have any disabilities or othermedical conditions not already discussed above, please let us know, so we can make every effort to address all your healthcare needs. By answering the questions below, you can help us to best assess your needs;Do you have any problems with vision?Do you have any problems with hearing?Do you have any disabilities affecting your mobility?Do you have any problems communicating with others?Do you have any learning or cognitive disabilities?Do you have any developmental disabilities?0 YES 0 NO0 YES 0 NO0 YES 0 NO0 YES 0 NO0 YES 0 NOOYESONOIfyou have answered yes to any of these,please explain:Briefly describe the main concerns you have about your health on the back of this sheet.