NAME____________________________ DATE OF BIRTH_______________
AGE_________ MARITAL STATUS__________________________________
PRESENT PROBLEM AND / OR COMPLAINTS________________________
_________________________________________________________________
REFERRING PHYSICIAN OR PATIENT_______________________________
PRIMARY CARE PHYSICIAN_______________________________________

Father:Living?_____ Age______If deceased, cause_________________
Mother:Living?____ Age______If deceased, cause_________________
Brothers:Living?____ Age______If deceased, cause_________________
Sisters:Living?____ Age______If deceased, cause_________________
Children:Living?____ Age______If deceased, cause__________________
Have any members of your immediate family had any kidney, bladder or urinary tract problems?_________________________________________________________

Have you had any of the following: (please check)
High blood pressure______ Asthma______ Mumps______ Gout______
Heart disease______ Arthritis______ Pneumonia______ Diabetes
Rheumatic fever______ Tuberculosis______ Syphilis______ Hepatitis______
Gonorrhea______ Bleeding disorder______
Presently under treatment for:_________________________________________
Have you had any previous bladder or kidney problems?____________________
Have you ever had kidney x-rays?______________________________________
If so, where and when?_______________________________________________

Do you use any of the following? (note amount per day)
Alcohol________ Tobacco_________ Coffee_________ Tea___________
Other___________________________ Medication___________________
Prescribed by?______________________________________________________
Do you take aspirin-containing medications such as Alka Seltzer, Bufferin, Excedrin, etc.?______________________________________________________________
Are you allergic to any medications?____________________________________
Approximate daily fluid intake_________________________________________
Regular bowel movements?___________________________________________

Please give date, hospital, illness and attending physician for previous hospital admissions, including surgery:_________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

Are your periods: REGULARIRREGULARNONE(circle one)
Are you taking birth control pills? YESNO(circle one)
Are you taking hormones? YESNO(circle one)
Date of last pap smear_______________________________________________

Today's Date:______________________________________________________