Advanced Urology Institute | Urologists in Florida



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6 Physician Signature-______________________________ Date-___/___/___

A45519 (6/02)

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Review of Systems: Do you have any of the following symptoms?

Fever/Chills Y N Chest Pain Y N

Nausea/Vomiting Y N Shortness of Breath Y N

Headache Y N Cough Y N

Weight Loss Y N Wheezing Y N

Loss of Appetite Y N Back/Neck/Joint Pain Y N

Dizziness Y N Blood Clotting Problem Y N

Tired/Sluggish Y N Sinus Problems Y N

Abdominal Pain Y N Blood in Urine Y N

Heartburn/Indigestion Y N Burning with Urination Y N

Blurry Vision Y N Urinary Leakage Y N

2 Allergies-_____________________________________________________________________

1 Patient Name:_____________________

Primary Doctor:___________________

Date:____/____/____

Established Patient Follow-Up Form

follow

Reason for Appointment:

Past Medical/Social History Update:

List of Current Medications-________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

List Any Recent Surgeries-__________________________________________________________

_________________________________________________________________________________

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List Any New Medical Conditions-____________________________________________________

_________________________________________________________________________________

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Do You Smoke? Y N Quit _____ years ago

How Much Do You Smoke?________________________

HPI: (Physician Section)

(Need 4 Bullets or 3 Diagnoses for Level 4 or 5) (25 minutes = Level 4) (40 minutes = Level 5)

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