Advanced Urology Institute | Urologists in Florida
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6 Physician Signature-______________________________ Date-___/___/___
A45519 (6/02)
-----------------------
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-__________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
List Any New Medical Conditions-____________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
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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