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Current Patient Questionnaire
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Current Patient Questionnaire
Patient
Demographics
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Married
Single
Widowed
Divorced
Pharmacy Info
Insurance Info (Please bring insurance Card to visit)
Would you like us to communicate with you by email?:
Yes
No
***Physical signature will be required upon office visit.***
Receipt of Privacy Practices (HIPPA)
I have received a copy of Rebecca Kurth, MD's Notice of Privacy Practices:
Yes
No
***Physical signature will be required upon office visit.***
Patient
Questionnaire
Social Background
Please provide an update of the following information since your last check-up
Family Background
Please note any changes in health status of the following:
General Review
Do you excersise regularly?
Yes
No
Over the past year have you lost or gained weight?
Yes
No
Are you happy with your current weight?
Yes
No
Please check any of the following symptoms that you may be experiencing:
General
Fatigue
Hot Flashes
Tiredness
Night Sweats
Head and Neck
Headaches
Change In Vision
Double Vision
Blurred Vision
Sore Throat
Sinus Problems
Tingling In Hands
Hoarseness
Lumps In Neck
Pain In Neck
Weakness In Hands
Lungs
Wheezing
Cough
Shortness Of Breath
Heart
Palpitations
Chest Pain
Lightheadedness
Dizziness
Chest Tightness
Racing Heart
Abdomen
Pain
Blood In The Stool
Indigestion
Diarrhea
Constipation
Incontinence
Muscular-skeletal system
Pain in:
Shoulders
Back
Knees
Hips
Feet
Elbows
Hands
Neck
Swelling in:
Shoulders
Knees
Feet
Elbows
Hands
Endocrine
Increased Thirst
Increased Nightly Urination
Increased Appetite
Change In Size Of Gloves Or Hat
Neurologic
Trouble With Speech
Stroke
Weakness In The Arms/Legs
Myasthenia Gravis
Tingling
Memory Problems
Tremors
Parkinson's Disease
Headache
Multiple Sclerosis
Paralysis
Dermatologic
Rash
Moles
Itching
Hair Loss
Nail Discoloration
Mood
Depressed
Down
Anxious
Blue
Panicky
Irritable
Stressed Out
Worried
Nightmares
Overeating
Bulimia
Anorexia
Thoughts Of Hurting Yourself
Men - Urinary System
Have you consulted with a urologist this year?
Yes
No
Have you had a PSA test in the past year?
Yes
No
Do you have any concerns about your sexual functioning?
Yes
No
Are you concerned about HIV risk?
Yes
No
Have you ever been tested for HIV?
Yes
No
Would you like to be tested today?
Yes
No
Do you experience:
Burning Urination
Frequent Urination
Blood In The Urine
Painful Urination
Incontinence
Difficult Urinary Stream
Lumps On Testicles
Hernias
Lumps On Groin
Women - Urinary System
Are your cycles regular?
Yes
No
Do you have any lumps in your breasts?
Yes
No
Are you concerned about HIV risk?
Yes
No
Have you ever been tested for HIV?
Yes
No
Would you like to be tested today?
Yes
No
Do you experience:
Burning Urination
Incontinence
Blood In Urine
Urinary Frequency
Travel
Do you have plans to travel outside of the US this year?
Yes
No
Exam Dates
Please supply approximate dates for the following:
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