Patient Registration Form Patient Registration Form Patient InformationName(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Date of Birth(Required) Day Month Year Occupation(Previous if retired) Reason for this urological consultation:Please list other medical professionals involved in your care:Do you have or ever been told you have any of the following conditions? Kidney disease Kidney stones Prostate issues Bladder problems Do you have a current referral from another doctor (either GP or specialist)? YES NO Please elaborateGeneral Medical HistoryDo you have any allergies?(Required) YES NO known allergies Please list known allergies (e.g. medications, foods, or other) and the type of reaction:(Required)Are you taking any medications, nutritional supplements, vitamins, and over the counter medications?(Required) YES NO Please list any medications, nutritional supplements, vitamins, and over the counter medications you take.Are you on any medications that THIN your blood? e.g. Warfarin, Plavix YES NO If YES, please list your blood thinning medication. Are you on any medications that decrease your immune system? e.g. Predinsolone, Chemotherapy Medications. YES NO Please elaborate Do you have or ever been told you have any of the following conditions? Please tick. Heart Valve Replacement YES NO WHEN and WHERE did you have your Heart Valve Replacement? Heart Arrhythmias or AF YES NO Please elaborate Have you ever had Angina? YES NO Please elaborate Have you ever had a Coronary Stent or Heart Surgery? YES NO If YES, what year was your surgery? Diabetes YES NO Do you manage your diabetes with diet, tablets or insulin? High Blood Pressure YES NO Please elaborate Low Blood Pressure/Dizziness YES NO Please elaborate Lung/Respiratory Problems (e.g. Asthma, COPD, Emphysema) YES NO Please elaborate Liver Problems e.g. Hepatits YES NO Please elaborate Bowel Problems YES NO Please elaborate Blood Disorders YES NO Please elaborate Cancer YES NO Please elaborate Joint Replacements YES NO Please elaborate Stroke/TIA's YES NO Please elaborate DVT or Pulmonary Embolism YES NO Please elaborate Sleep Apnoea YES NO Please elaborate Have you ever had back surgery? YES NO What type of back surgery and when? Urological Surgery e.g. TURP YES NO What type of urological surgery and when? Gynaecological Surgery e.g. Hysterectomy YES NO What type of gynaecological surgery and when? Neurological Conditions e.g. Multiple Sclerosis YES NO Please elaborate Do you currently smoke? YES NO How many per day? How many years have you smoked? Have you ever been a smoker? YES NO When did you stop smoking? Do you drink any alcohol? YES NO How many standard drinks per day? Or week? Please list any other serious illnesses/conditions not listed above.Family Medical HistoryPlease tick if any family member/s have had the following cancers. Breast Cancer Prostate Cancer Any relevant family medical history?Consent(Required) I agree to the privacy policy.I understand that the information that I have given today is correct to the best of my knowledge. I also understand that it is my responsibility to inform this office of any changes in my medical status. Signature(Required)Full Name(Required) Date(Required) DD slash MM slash YYYY EmailThis field is for validation purposes and should be left unchanged. Δ
