AJAX UROLOGY ASSOCIATES
95 Bayly St. W., Ste. 300, Ajax , ON, L1S 7K8
Tel : (905) 426-9426, Fax: (905) 426-9322

PLEASE FILL OUT COMPLETELY:

Name (first) (last) Age: Sex: Male Female

Date of Birth: (d) (m) (y) OHIP #: Version:

Address: (street) (apt)

(city) (postal code)

Phone #: (home) (work) (cell or other)

Family Doctor: Referring Doctor:

Family MD Fax #: Referring MD Fax #:

Have you been to this office before? Yes No If yes, when?

 

SOCIAL HISTORY:

What is your marital status; are you married, single, divorced, separated or widowed?

Do you have any children and, if so, how many? Is there any chance that you are pregnant?

Are you currently working and, if so, what do you do?

If you are retired, what did you do before retirement?

Do you have a drug plan? Yes No

PAST MEDICAL HISTORY:

Please list any medical conditions that you have or have been treated for in the past: (e.g.: Heart attack, heart failure, angina, diabetes, stroke, asthma, bronchitis, high blood pressure, high cholesterol, thyroid problems, hepatitis, infections, kidney stones, others)

Please list any surgery you have had:

Please list the medications and their doses that you take: (including prescription, over-the-counter, herbals and birth control)

Do you take any blood thinning medication? (Coumadin, Aspirin, Plavix, Advil, Motrin or Ibuprofen) Yes No

Do you use or have you ever used nitroglycerin ? Yes No If yes, how often and when is the last time?

Please list any allergies that you have: (including medication and dye allergies -- if you have none, please indicate)

Do you smoke? Yes No If no, have you ever smoked? Yes No If yes, when did you quit? and answer the question below

If yes, how much and for how many years total? (packs per day) X (years)

Do you drink any alcoholic beverages? Yes No If yes, on average how many drinks per week?

Family history of illness?

cancer ? Yes No