1434 Broadrick Drive
Dalton, Georgia 30722

Phone:706/278-5961 | Fax: 706/275-0280

Primary / Referring Doctor

Date of last physical exam?

What is the main reason you are being seen today? 

Have you seen this condition before?

Have you ever been seen by a Urologist?

Men: Do you get your PSA checked regularly?

If so, when was it last checked? 

What was the result (number)? 

History Of Present Illness

How long have you had this problem? 

Where is the problem located?

If painful, how would you describe (cramp, ache, sharp, dull, burn, etc)? 

On a scale of 1 to 10, most severe being 10, please rate your pain.

How long does the problem last? Choose one.
 Minutes  Hours  Days  All the time

Do any other problems or conditions occur at the same time? yes or no
 Yes  No

If YES please explain:

Urologic History

Check All That Apply

Cervical Cancer 

Bladder Cancer 

Kidney Cancer 

Other Cancer 

Interstitial Cystitis 

Pain w/ sex 

Dropped Bladder 

If you still have periods, when was your last one?

Have you ever had the following? (check if yes)

Urine Leakage 

Bowel Leakage 

Painful Urination 

Slow Urination 

Straining to Urinate 

Drop Bladder 

Kidney Stone 

Urinary Infection 

Blood in Urine 

Kidney Disease 

Kidney Failure 

Dialysis 

Urinary Surgery 

Urinary problems as a child 

Mumps after puberty 

Injury to urinary tract 

Erection / Sexual Problems 

Please list all medications including over the counter drugs (NON Prescription)

Spefically

Medical History

Have you ever had any of the following?

Heart Attack 

Heart Failure 

Heart Murmur 

Atrial Fibrillation 

Mitral Valve Prolapse 

Sickle Cell Disease 

Anemia 

High Blood Pressure 

Parkinsons 

Pacemaker 

Blood Clotting Problem 

Radiation 

Chemotherapy 

Rheumatic Fever 

Stomach Ulcers 

Diverticulosis 

Glaucoma 

Alzheimer's 

Tuberculosis 

Emphysema / COPD 

Thyroid Condition 

GERD 

Diabetes 

Hepatitis 

Seizures 

Stroke / Mini 

Gout 

DRUG ALLERGIES (if none please state):

Surgeries

List all operations you have had and the year of the surgery:

Family History

Has anyone in your immediate family (parents, siblings, grandparents) had the following?

Prostate Cancer 

Bladder Cancer 

Kidney Cancer 

Kidney Stones 

Kidney Failure 

Blood in Urine 

Heart Attack 

Bleeding Problems 

Blood Clots 

High Blood Pressure 

Heart Failure 

Stroke 

Social History

Do you smoke or have you ever smoked?
 Yes  No

Do you drink alcohol?
 Yes  No

If so how much?

How much caffeine (coffee, tea, soda) do you consume daily?

Do you use recreational or IV drugs? (marijuana, cocaine, etc)
 Yes  No

Marital Status:
 Single   Partnered   Married   Separated   Divorced   Widowed 

What do you/did you do for a living?

Have you traveled outside the U.S. recently?
 Yes  No

Have you ever had a blood transfusion?
 Yes  No

If so, did you have a negative reaction?
 Yes  No

ROS:

Check Y if you are CURRENTLY having any of these symptoms. Circle N if you do not.

Constitutional

Fever
 Yes  No

Chills
 Yes  No

Night Sweats
 Yes  No

Weight Loss
 Yes  No

Any other?:

Cardiovascular

Chest pain (angina)
 Yes  No

Irregular Heartbeat
 Yes  No

Short of breath at rest
 Yes  No

Short of breath w/ exertion
 Yes  No

Poor Circulation
 Yes  No

Swelling of legs/ankles
 Yes  No

Eyes

Cataracts
 Yes  No

Glaucoma
 Yes  No

Any other?:

Integumentary

Boils
 Yes  No

Skin Rash
 Yes  No

Any other?:

Allergic/Immunologic

Hay Fever
 Yes  No

Asthma
 Yes  No

Drug Allergies
 Yes  No

Environmental
 Yes  No

Any other?:

Musculoskeletal

Back Pain
 Yes  No

Arthritis
 Yes  No

Weakness
 Yes  No

Fibromyalgia
 Yes  No

Any other?:

Neurological

Dizzy Spells
 Yes  No

Numbness
 Yes  No

Tingling
 Yes  No

Slipped Disc
 Yes  No

Herniated Disc
 Yes  No

Headaches
 Yes  No

Any other?:

Ears/Nose/Throat

Dry Mouth
 Yes  No

Sore Throat
 Yes  No

Sinus Issues
 Yes  No

Hearing Loss
 Yes  No

Hearing Issues
 Yes  No

Any other?:

Endocrine

Hyperthyroid
 Yes  No

Hypothyroid
 Yes  No

Diabetes
 Yes  No

Any other?:

Respiratory

Bronchitis
 Yes  No

Wheezing
 Yes  No

Frequent Cough
 Yes  No

Must sleep sitting up
 Yes  No

Cough Up Blood
 Yes  No

Any other?:

Gastrointestinal

Constipation
 Yes  No

Diarrhea
 Yes  No

Vomiting
 Yes  No

Bloody Bowels
 Yes  No

Hemorrhoids
 Yes  No

Hernias
 Yes  No

Any other?:

Hematologic/Lymphatic

Bruise Easily
 Yes  No

Bleeding Problem
 Yes  No

Swollen Glands
 Yes  No

Any other?:

Psychological

Anxiety
 Yes  No

Depression
 Yes  No

ARE YOU SATISFIED WITH YOUR LIFE
 Yes  No

Financial Policy

• Payment in full is due at the time of service (including private pay, co-payments, and deductibles).
• Failure to pay at time of service, bring your insurance card, or have a referral, may result in your appointment being rescheduled.
• There will be a $25.00 fee charged for broken appointments unless 24 hours notice is given.
• There will be a $50.00 fee for a copy of medical records/FMLA forms. This charge is to be paid in full prior to receiving medical records and/or FMLA documents.
• Insurances we participate with include Medicare, 1 sr Medical Network, Health One Alliance, Alliant, Aetna, Shaw, Beaulieu, Tri-Care, Humana, Mohawk, CBSA, BCBS of Georgia and PHS.
• We accept CASH, CHECKS, VISA, MASTERCARD, AMERICAN EXPRESS, DISCOVER and CARECREDIT. Applying for CareCredit only takes a few minutes and there is no fee to apply. Please make note that there is a $35.00 charge for all returned checks.
• Insurance is a contract between you and your insurance company and not a substitute for payment. You are responsible for payment of your bill regardless of any insurance company arbitrary determination of usual and customary rates and the services that are not considered covered expenses under your medical plan. If you are not able to comply with the above policy, you may contact our office at 706-278-5961 anytime to discuss other arrangements. These arrangements must be made prior to your office visit or surgery.
• If an account becomes outstanding, we will liquidate the account by one of the following methods:

  • Refer discharged debt to a Collection Agency.

    (In the event your account is delinquent and placed with a collection agency you are responsible for the collection fee of 35% of the account balance is liquidated damages, and if an attorney is hired to collect, after maturity, 15% of unpaid principal and interest owing on said account as attorneys' fees .. )

• Report discharged debt as income to the IRS.

  (Under SS 108 (e)(2), 262 and 213 of the Internal Revenue Code, a discharge of debt produces income for the debtor.)

• Surgeries: Elective surgeries require payment in full. due in the office by 2:00 pm the day before surgery. or your surgery may be cancelled. The remaining balance can be set-up with the billing department.

I have read and understand the above financial policy. I give authorization to release any and all necessary information to my insurance company for the processing of a claim. I also authorize that payment be made directly to the physician. A photostatic copy of this authorization will be as valid as the original.

Acknowledgement and Consent Notice

Communication Consent

HIPAA is an acronym for the Health Insurance Portability & Accountability Act of 1996 a federal law. The Administrative Simplification section of the act is of concern to our practice and requires us to comply with specific rules regarding:

• Unique identifiers for health plans, providers, individuals, and employers.
• Healthcare transactions & code sets for transmitting electronic data.
• Privacy regulations over disclosure and use of health information.
• Security regulations over protections of electronic health information.

All of the rules have been developed by the Department of Health & Human Services and will become final in a staged manner.

It will be the policy of North Georgia Urology Center to not release confidential and/or unauthorized information by home telephone, answering machine, work telephone, voicemail, postal mail, cellular phone, pager and/or fax. Whenever returning telephone calls and an answering machine picks up, we will not leave a message if the name or telephone number is not on the recorded message to identify the residence. Information will not be left with an unauthorized person who may answer your telephone.

If you would like to have your medical information released to someone other than yourself, please complete the following.

I authorize North Georgia Urology Center to release medical information to the following people including my listed emergency contact.

BLADDER SATISFACTION SURVEY

PELVIC PAIN and URGENCY/FREQUENCY

Which symptoms best describe you?

Frequent Urination-Day, Night, or Both 

Sudden or strong urge to urinate 

Unable to empty the bladder 

Leaking with Sneezing, Coughing, Exercising 

Leaking with Urge or No warning (not making it to the restroom in time) 

Bladder or pelvic pain 

How long have you had these symptoms? 

Have you tried medications to help your symptoms?
 Yes  No

If yes, check the medications you have tried:

Detrol LA 

Oxytrol Patch 

Sanctura 

Ditropan XL  

Enablex 

Elavil  

Flomax  

VESlcare 

Elmiron  

Cardura  

DDAVP  

Gelnique 

Toviaz  

Other:  

Did these medications help your symptoms?
Scale 1-10 (0 being no relief and 10 completely cured)

If you've stopped taking your meds explain why:
 

Describe Side Effects
 

Behavior Modifications Tried (i.e., caffeine intake, lifestyle changes, bladder training, pelvic floor muscle training)

What is your level of frustration with your bladder symptoms?
Scale 1-10 (0 being Not Frustrated and 10 Very Frustrated )
 

Do you currently have any problems with bowel functions?

 Fecal Incontinence   Constipation  Other

I am interested in learning more about treatment alternatives to medications:
 Yes  No

PATIENT SYMPTOM SCALE

Please select the answer that best describes how you feel for each question.

1. How many times do you go to the bathroom during the day?
 3-6  7-10 11-14  15-19 20+

2.
a. How many times do you go to the bathroom at night?
 0  1 2  3 4+

b. If you get up at night to go to the bathroom does it bother you?
 Never  Mildly Moderate  Severe

3. Are you currently sexually active? Yes  No

4.
a. IF YOU ARE SEXUALLY ACTIVE, do you now or have you ever had pain or symptoms during or after sexual intercourse?
 Never  Occasionally  Usually  Always

b. If you have pain, does it make you avoid sexual intercourse24
  Never  Occasionally  Usually  Always

5. Do you have pain associated with your bladder or in your pelvis (vagina, lower abdomen, urethra, perineum, testes, or scrotum)?
 Never  Ocasionally  Usually  Always

6. Do you have urgency after going to the bathroom?
 Never  Ocasionally  Usually  Always

7.
a. If you have pain, is it usually
 Mildly  Moderate  Severe

b. Does your pain bother you?
 Never  Occasionally  Usually  Always

8.
a. If you have pain, is it usually
 Mildly Moderate  Severe

b. Does your pain bother you?
 Never  Occasionally  Usually  Always

Final Signature and Date

Print Name

Patient Signature or Responsible Party

Todays Date: