Language
English (US)
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New Patient Intake form:
Version 06.08.23
Patient Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Secondary Contact
First Name
Last Name
Relationship
Phone Number
-
Area Code
Phone Number
Pharmacy Details
Pharmacy Name
Street Address
City
State / Province
Postal / Zip Code
Pharmacy Phone Number
-
Area Code
Phone Number
Comments
History of Present Illness
Height
*
Weight
*
Which best describes the main reason for TODAY'S visit?
*
Blood in the urine (including microscopic)
Constipation or Fecal Incontinence
Ejaculatory issue (premature ejaculation/hematospermia)
Elevated PSA
Exposed Vaginal Mesh
GU Fistula (including vesicovaginal fistula/rectovaginal fistula)
Hydronephrosis or kidney cyst
Infertility
Kidney/ureter/bladder stone
Low Testosterone
Menopause
Neurogenic bladder
Pelvic organ prolapse (including cystocele/rectocele)
Pelvic or Vaginal Pain
Penile Girth Enhancement
Penile Issue (including balanitis/phimosis/circumcision consult/Peyronie's/condyloma)
Sexual or Erectile dysfunction (all genders, including decreased libido and sensation)
Swelling or pain of the scrotum or testicles (including hydrocele, spermatocele, varicocele, epididymitis)
Urinary symptoms (including frequency, urgency, straining, retention, leaking, incontinence, BPH)
Urethral Diverticula
Urethral prolapse/caruncle
Urinary Tract Infection or Prostatitis or Interstitial Cystitis
Vasectomy
Other
Choose any other conditions you want to discuss at FUTURE visits (select all that apply)
Blood in the urine (including microscopic)
Constipation or Fecal Incontinence
Ejaculatory issue (premature ejaculation/hematospermia)
Elevated PSA
Exposed Vaginal Mesh
GU Fistula (including vesicovaginal fistula or rectovaginal fistula)
Hydronephrosis or kidney cyst
Infertility
Kidney/ureter/bladder stone
Low Testosterone
Menopause
Neurogenic Bladder
Pelvic organ prolapse (including cystocele or rectocele)
Pelvic or vaginal pain
Penile Girth Enhancement
Penile Issue (including balanitis/phimosis/circumcision consult/Peyronie's/condyloma
Sexual or Erectile dysfunction (all genders, including decreased libido and sensation)
Swelling or pain of the scrotum or testicles (including hydrocele, spermatocele, varicocele, epididymitis)
Urethral Diverticula
Urethral prolapse/caruncle
Urinary symptoms (including frequency, urgency, straining, retention, leaking, incontinence, BPH)
Urinary Tract Infection or Prostatitis or Interstitial Cystitis
Vasectomy
Other
Are you allergic to the following? (Select all that apply)
*
Latex
Shellfish
Band-aids/Adhesives
IVP Dye
Iodine
No known allergies
Other
List all MEDICATION ALLERGIES (Name of Medication-Reaction to Medication)
List all HOSPITALIZATIONS, including the year (not ER visits)
List all SURGERIES. (Select all that apply)
Appendectomy
Artificial urinary sphincter
Bladder surgery
Bladder botox
Bowel surgery
Cholecystectomy/gall bladder removal
Cystectomy/bladder removal
Gender affirmation surgery
Hypospadias repair
Hysterectomy
Kidney stone removal
Kidney surgery
Mid-urethral sling
Nephrectomy/kidney removal surgery
Oopherectomy/ovary removal
Penile implant
Penile surgery
Prostatectomy
Prostate surgery
Sacral neuromodulation (Interstim®, Axonics®)
Scrotal surgery
Testicular surgery
TURP
Urethral surgery
Vaginal prolapse surgery
Vaginal surgery
Vasectomy
List all surgeries not mentioned above. (Please specify)
Please select if you have been diagnosed with or have a history of any of the following conditions:
abnormal pap smear
acute coronary syndrome
AIDS/HIV
anxiety
benign prostatic hyperplasia
bladder cancer
breast cancer
cerebrovascular accident
cervical cancer
chronic bladder infections
chronic obstructive pulmonary disease
congestive heart failure
constipation
deep vein thrombosis
depression
diabetes
elevated PSA
endometrial cancer
endometriosis
end-stage renal disease
erectile dysfunction
estrogen replacement therapy
fecal incontinence
fibromyalgia
hypertension
hypogonadism
inflammatory bowel disease
irritable bowel syndrome
kidney stones
kidney transplant
menopause
multiple sclerosis
myocardial infarction
obstructive sleep apnea
osteoarthritis
ovarian cancer
pelvic organ prolapse
prostate cancer
pulmonary embolism
renal cell cancer
sickle cell disease
sickle cell trait
testicular cancer
urethral diverticulum
urinary incontinence
urinary tract infection
urostomy
vulvodynia
Other
OTHERS (Please list down all the past medical conditions)
I authorize Metro Atlanta Urology and Pelvic Health Center to retrieve my external prescription history
Yes
No
Please List All Medications
*
Rows
Medication Name
Dosage Amount
#Taken Daily
Ordering Doctor
Start Date
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Tobacco Usage:
*
Yes, I Smoke Daily
Yes, Sometimes I Smoke
No, I Quit Smoking
No, I Never Smoked
How many packs per day?
How many years?
Have you tried to quit?
Alcohol Consumption
*
I don't drink
1-4 drinks/month
1-2 drinks/day
3-4 drinks/day
5+ drinks/day
Caffeine Consumption
*
I don't use caffeine
1-4 cups/month
1-2 cups/day
3-4 cups/day
5+ cups/day
Number of Pregnancies
Number of children born
Are you currently pregnant?
Marital Status
*
Single
Married
Separated
Divorced
Widowed
Living with significant other
Not answered
What is your current living arrangement?
*
Live alone
Live with family/friend
Assisted living
Nursing home
Do you have an Advanced Directive?
*
Yes
No
Do any one of your family members have any of the following:
*
Genitourinary (kidney/prostate/bladder/testicle) cancer
Breast cancer
Kidney stones
Urinary stones
Sickle cell anemia
Not applicable
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Review of Symptoms
Have you experienced any of the following within the last 30 days?
*
Rows
Yes
NO
Abdominal Pain
Back Pain
Black Stool
Bloody Stool
Blurred Vision
Bone Pain
Changes in Appetite
Changes in Vision
Chest Pain
Chills
Cold Intolerance
Cough
Decreased Urinary Stream
Deep Vein Thrombosis (Clots)
Dermatitis
Diarrhea
Easy Bleeding
Easy Bruising
Excessive Thirst
Fatigue
Fever
Frequent Urination at Night
Frequency of Urination
Headaches
Heart Murmurs
Heat Intolerance
Impotence
Incontinence
Irregular Heartbeat
Joint Pain
Lack of Coordination
Lumps in Chest/Breasts
Muscle Pain
Nasal Congestion
Nausea
Nipple Discharge
Numbness or Tingling
Painful Urination
Pelvic Pain
Post-Void Dribbling
Rapid Ejaculation
Seizures
Scrotal Pain
Shortness of Breath
Sinus Pain
Skin Rash
Swelling in Chest/Breast
Tenderness in Chest/Breast
Urgency
Vaginal Pain
Vomiting
Weight Gain
Weight Loss
Wheezing
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