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Arizona State Urological InstituteThe Center for Comprehensive Urological CarePatient Name:Date of Birth://Please answer the following to the best of your ability. If you are unable to fill out these forms or needassistance, ask the front desk for additional help.I authorize the following people to access my medical records and information:Name (First and Last)Date of Birth (MM/DD/YYYY)////////RelationshipArizona State Urological Institute (ASUI) commitment to protecting your privacy and ensuring that yourhealth information is used and disclosed properly. Please select a security question below to verify with theindividuals who are authorized to access and discuss your medical records with our office. Security PIN: Security Question:Answer: Security Phrase:Ok to leave a detail message:NoDo you have any children?Do you currently smoke?Are you a former smoker?Do you chew tobacco?Do you drink alcohol? [ ] No[ ] Yes[ ] Yes[ ] Yes[ ] Yes[ ] sociallyHave you ever used illegal drugs?Yes[[[[List Number ok to leave message on:] No] No] No] No[ ] 1-2 per day[ ] Yes[ ] No[ ] Yes[ ] NoIf yes, how many:If yes, how often:If yes, how many years:[] 3-4 per dayIf yes, list what kind(s):Are you currently sexually active?Have you ever had a sexually transmitted disease (STD)?If yes, please list type:Type:Type:[ ] Yes[ ] NoDate:Date:Date:[ ] Over 4 per day
Arizona State Urological InstituteThe Center for Comprehensive Urological CarePATIENT CONTACT LISTPlease provide current information that our office can use to contact individuals on your behalf in case ofdisconnected number, difficulty with reaching you, or an emergency.Emergency Contact: Indicate any person who should be notified in case you experience amedical emergency while at our office.EMERGENCY CONTACTName:Date of Birth://Relationship:Primary Phone: ()-Alt. Phone: ()-Non-Emergent Contact: Indicate persons who we may contact if we are having difficultyreaching you. Note: Unless you authorize the following individuals to access your protected healthinformation (PHI), they may not receive test results or office visit information on your behalf.NON-EMERGENT CONTACT #1Name:Date of Birth://Relationship:Primary Phone: ()-NON-EMERGENT CONTACT #2Name:Relationship:Primary Phone: ()-NON-EMERGENT CONTACT #3Name:Relationship:Primary Phone: ()-Print Patient Name:Signature of patient or patient representativeAlt. Phone: ()Date of Birth:Alt. Phone: (//)Date of Birth:Alt. Phone: (--//)-Date//
Arizona State Urological InstituteThe Center for Comprehensive Urological CareACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICESArizona State Urological Institute (ASUI) is commitment to protecting your privacy and ensuring that yourhealth information is used and disclosed properly. This Notice of Privacy Practices identifies all potentialuses and disclosures of your health information by our Practice and outlines your rights regarding yourhealth information. Please sign this form below to acknowledge that you have received our Notice ofPrivacy Practices.I acknowledge that I have received a copy of the Notice of Privacy Practices of Arizona State UrologicalInstitute.Signature of Patient or Personal RepresentativePrinted name of Patient or Personal RepresentativeDate//
Arizona State Urological InstituteThe Center for Comprehensive Urological CareWhat medical conditions have you been diagnosed with (Example: Diabetes, high blood pressure,etc.) No Known past medical conditionsList conditions below:What medical conditions are in your family history (Example: Diabetes, high bloodpressure, etc.) No Past Medical History KnownList family member condition:RelativeAre you allergic to any medications or medical products? No Known Drug AllergiesList allergyPast Surgical Procedures/ Surgeries. No prior surgical procedures or surgeriesReactionList name, where and date please.
Arizona State Urological InstituteThe Center for Comprehensive Urological CarePlease list the medication that you take currently. (If you have a list, please turn list in with yourpacket, or front desk can make a copy for your chart.) If taking No medications, write N/A orNONE.Medication Name:Strength:Frequency:Duration:Preferred Pharmacy Information: (List Local and Mail order if applicable)Local Pharmacy Name:Phone Number: ()-)-Address or Cross Streets:Probable Zip Code:Preferred Mail Order Pharmacy:Pharmacy Name:Phone Number: (
Arizona State Urological InstituteThe Center for Comprehensive Urological CarePlease review the following checklist, and only check the medical conditions that apply to you. (Ifa condition applies to someone in your family, but you do not have it, do not check the box for thatcondition.)Constitutional Recent appetite change Recent weight gain Recent weight loss Fatigue Fever ChillsGastrointestinal Bloody stools Recent bowel changes Abdominal pain Nausea Heartburn Diarrhea ConstipationSkin Hives Itching RashAllergy/Immunologic Cancer (Type: Seasonal AllergiesENMT Hearing change Nosebleeds Tinnitus (Ringing in ears)Eyes/Head Dizziness Headaches Changes to visionRespiratory Shortness of breath Cough WheezingCardiovascular Edema (Swelling) Chest pain/discomfort Syncope (Fainting))Genitourinary Weak urinary stream Painful urination FEMALES: Vaginal discharge MALES: Penile dischargeEndocrine Diabetes (Type 1 or int stiffnessBack pain/injuriesArthritis Neurological Epilepsy Palsy Speech changes Stroke TinglingHematologic/Lymphatic Anemia (Low iron) Easy bruising)
Arizona State Urological Institute (ASUI) commitment to protecting your privacy and ensuring that your health information is used and disclosed properly. Please select a security question below to verify with the individuals who are authorized to access and discuss your medical records with our office. Security PIN:
