Legal Name Name You Go By

Legal Name Name you go by

Social Security# Date of Birth _____/______/______

Address City State Zip

Home Phone ______Cell Ph ______Wk Ph ______

Marital Status (circle one): Single Married Divorced Widow Sex: Male Female

Email ______@ ______

Would you like access to the Patient Portal YES______NO______

Referral Source (circle one)? Yellow Pages, Friend/Relative, Hospital ______, Insurance, Internet

Referring Physician Phone

Primary Care Physician (if different from Referring Physician listed above):

Name Phone

Patient’s Employer Occupation

Emergency Contact ______Phone

Relationship to emergency contact: ______

Insurance Policy Holder Information (if insurance is through spouse or parent)

Primary Insurance Information:

Name Relationship Date of Birth Phone

Address City State Zip

Social Security Number Employer Work Phone

Secondary Insurance Information:

Name Relationship Date of Birth Phone

Address City State Zip

Social Security Number Employer Work Phone

Preferred Pharmacy Information

Preferred Pharmacy Phone

ASSIGNMENT OF BENEFITS, AUTHORIZATION TO RELEASE MEDICAL INFORMATION:

I request that payment of authorized benefits from my insurance carrier be made either to me or on my behalf to Urology Associates of Central MO for any services furnished to me by my provider. I authorize any holder of medical information about me to release it to the following when applicable to determine benefits for related services: Division of Family Services, Centers for Medicare and Medicaid Services, insurers and/or agents of these companies, responsible person(s) listed, Name of authorized person (specify relationship) or other healthcare providers assisting in my medical care.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES:

I have been offered a copy of Urology Associates of Central MO Notice of Privacy Practices.

CONSENT TO TREATMENT:

I authorize Urology Associates of Central MO and/or any physician or authorized persons employed by them to perform and/or initiate medical evaluation and treatment and authorize and/or order any related services on my behalf.

In the event that any personnel assisting in the provision of care and treatment suffer inadvertent exposure to any of my blood and/or other bodily substances that is capable of transmitting disease and I am unable to timely consult with my physician prior to testing, I consent to limited testing to determine the presence, if any, of antibodies to or infectious agents of hepatitis A, B, C and HIV.

I understand that in order for Urology Associates of Central MO to comply with the federally mandated initiative for electronic medication prescribing (e prescribing) software to send prescriptions over the internet to pharmacies. These transmissions are done in a safe manner that protects the privacy of personal information. I agree that Urology Associates of Central MO may request and use my prescription history from other healthcare provides or third party payers for treatment purposes as required by the above mentioned federal initiative.

FINANCIAL AGREEMENT:

I understand that I am financially responsible for any charges regardless of insurance coverage. Should I default, I agree to pay all cost of collections including interest applied by collection agency, court cost and attorney fees. Any suit filed may be brought in the county where services are rendered. I also understand and acknowledge that I am personally responsible to pay Urology Associates of Central MO in full for services that my health insurer will not cover due to non-payment of my health insurance premiums.

I have read and agreed to the provisions on listed on this form and accept the terms. A duplicate of this statement is considered the same as original.

Print Name: ______DOB: ___/____/____

______Date: ______

Signature of Patient (For patients 17 yrs of age or younger, parent or guardian MUST sign.)

______

If legal representative, relationship to patient

The patient above also authorized the disclosure of health and financial information to:

PLEASE CHOOSE FAMILY MEMBER OR FRIEND

(This is not permission to release your official medical record)

Names of Individual ______Phone #______

New Patient Medical History Form

Name: ______Date of Birth: ______Age_____ Today’s Date: ______

Who referred you to Urology Associates? ______

Primary Care or Family Physician: ______

Chief Complaint (What is the reason for your visit today?) ______

Medical History: Please check if you have experienced the following.

 Alzheimer’s Disease

 Arthritis

 Asthma

 Back Pain

 Cancer ______

 Chronic Obstructive Pulmonary disease (COPD)

 Congestive heart failure Coronary artery disease

 Diabetes mellitus

 Emphysema

 Gastro esophageal reflux disease (GERD)

 Glaucoma

 Gout

 Heart Attack

 Heart Murmur

 Heart Stents

 High Blood Pressure

 High Cholesterol

 History of Blood Clot

 Hyperlipidemia

 Hypertension

 Hypogonadism

 Inability to urinate

 Kidney Stones

 Lupus

 Mitral Valve Prolapse

 Morbid Obesity

 Multiple Sclerosis

 Neck Pain

 Osteoporosis

 Pancreatitis, Chronic

 Parkinson’s Disease

 Sleep Apnea

 Stroke

 Urinary Infections (#/mths______)

 Other______

3/8/2017

Past Surgeries: Please check if appropriate and list approximate year.

3/8/2017

 Appendectomy, Yr ____

 Back Surgery, Yr ____

 Carpal Tunnel Release, Yr __

 Choleystectomy, Yr___

 Colon Surgery, Yr____

 Cystoscopy, Yr ____

 Gallbladder, Yr ____

 Hip Replacement,left,Yr ____

 Hip Replacement,right, Yr ____

 Hysterectomy, Yr ____

 Kidney Removal, Yr___

 Knee Arthroscopy, left, Yr ____

 Knee Arthroscopy, right Yr ____

 Knee Replacement, left Yr ____

 Knee Replacement, right, Yr ____

 Pacemaker, Cardiac, Yr ____

 Tonsillectomy, Yr ____

 Tonsillectomy and Adenoidectomy, Yr ____

 Tubal Ligation, Yr ____

 Urethral Stents, Yr______

 Urolift, Yr ____

 Stone Removal, Yr ____

 Urethral Stents, Yr ____

 Colon Surgery, Yr ____

 Cystoscopy, Yr ____

 Other ______, Yr _____

3/8/2017

Family History: Place check appropriate box below.

3/8/2017

Diabetes Hypertension Heart Disease Mental Illness Cancer (type)

Unknown Family Member

Father

Mother

Brother

Sister

Paternal Grand Father

Paternal Grand Mother

Maternal Grand Father

Maternal Grandmother

Social History:

Marital Status: married, single, divorced, widowed How many children do you have? ______

Occupation (current or former): ______

Do you smoke? ___yes ___no if yes, how many packs per day? _____

Do you drink caffeine? ___yes ___no if yes, Number of cups per day? ______

Do you drink alcohol: ____yes____no if yes, how many drinks a week? ______

Review of Systems: Please circle Y for Yes or N for No on ALL symptoms below.

General/Constitutional

Change in Appetite Y N

Chills Y N

Fever Y N

Headache Y N

Weight Gain Y N

Weight Loss Y N

Allergy/Immunology

Seasonal allergies Y N

Ophthalmologic

Blurred Vision Y N

ENT

Decreased hearing Y N

Endocrine

Lethargic Y N

Cold intolerance Y N

Excessive thirst Y N

Heat intolerance Y N

Respiratory

Cough Y N

Cardiovascular

Chest Pain Y N

Shortness of Breath Y N

Swelling in hands/feet Y N

Gastrointestinal

Constipation Y N

Diarrhea Y N

Heartburn Y N

Nausea Y N

Vomiting Y N

Genitourinary

Urinary hesitancy Y N

Decreased force of stream Y N

Nocturia Y N

Urinary urgency Y N

Stress urinary incontinence Y N

Dribbling Y N

Urge incontinence Y N

Sexual difficulties Y N

Pain with intercourse Y N

Blood in urine Y N

Frequent urination Y N

Painful urination Y N

Musculoskeletal

Back problems Y N

Muscle aches Y N

Weakness Y N

Skin

Rash Y N

Neurological

Dizziness Y N

Memory Loss Y N

Psychiatric

Anxiety Y N

Depression mood Y N

Shortness of Breath Y N

Patient Signature______Date______

Pharmacy Name, Location and Phone
Allergies and reactions
Current medications and what condition you take the medication for.
Over-the-counter medications taken regularly (including vitamins, herbs, aspirin).

3/8/2017