Patient Name: ______________________________________________ Date: ____________________

Name Prefer to be Called: ____________________________________

Address: _________________________________ City: ___________________ State _________ Zip: __________

Phone-Cell: ___________________ Phone-Home: ______________________ Phone-Work: _________________

Email Address: ___________________________________ Preferred Method of Contact: Cell Home Email

Date of Birth: ____________________ Social Security #: _____________________ Sex: Male Female

Language Preferred: _________________________ Ethnicity: Hispanic/Latino Non-Hispanic/Latino

Race: White/Caucasian Black/African American Asian Other Marital Status: ____________________

Employer: ___________________________________________

Employer Address: ______________________________________________ Main # _________________________

Primary Care Physician: ______________________________ Referring Physician: _________________________

How were you referred to Urology Center of Columbus?

☐ Family/Friend ☐ Website ☐My insurance requires me to
☐ Returning Patient ☐ Internet Search ☐Yellow Pages: ☐ Book ☐ Online
☐ Hospital/ER ☐ Health Fair/Screening ☐ Newspaper: _____________________
☐ Radio ☐ Pharmacy ☐ Magazine/Phamplet
☐ Seminar ☐ Social Media Which one? ☐ Facebook ☐ Twitter ☐ Google+
☐ Television ☐ Billboard
☐ Physician Referral: Who? _______________________ Did you request us? ☐ Yes ☐ No
Emergency Contacts:
Please list who we should contact in case of an emergency?
______________________________________________ _______________________________ ________________________________
Name Relationship Phone

(Optional) Additional Contacts:

Urology Center of Columbus recognizes that you may have a spouse, physician, family members, etc., that may be a part of your
healthcare. If you would like for Urology Center of Columbus to speak with anyone assisting you with you care please list them
below.
______________________________________________ _______________________________ __________________________________
Name Relationship Limitations
______________________________________________ _______________________________ __________________________________
Name Relationship Limitations

I hereby authorize Urology Center of Columbus to discuss and/or release a copy of my health information to the
person/organization specified above.

________________________________________________________________ ___________________________________________
Patient Signature Date

Revised 5/2015
 FINANCIAL POLICY
Urology Center of Columbus, LLC welcomes you to our practice. We work hard to provide the highest quality care to you. Your clear
understanding of our Financial Policy is important to our professional relationship. Please remember that our contract for service is with you, and it
is our policy that you are responsible for our fees regardless of insurance coverage.
FEES DUE AT TIME OF SERVICE:
 Co-Pay, Co-Insurance, Deductible and Non-Covered Services
 Self Pay
 Medical Records, Special Forms and Letters (that fall outside of the normal course of insurance claims): Urology Center of Columbus’
Notice of Privacy Practice describes how medical information about you may be used and disclosed and how you may access this
information. Medical records will not be released without a written authorization. For continuity of care, your records may be released to
another physician’s office or healthcare facility or in the event of an emergency. To request and receive a copy of your medical records,
Urology Center of Columbus will charge to cover the photocopying and administrative costs. A schedule of fees is available upon request.
OTHER FEES:
 Late Fee: A late fee of $30.00 is applied to any account for nonpayment of the balance due.
 Returned Checks or Declined Post dated credit card transactions: There is a fee of $35.00 for any checks returned by the bank or
declined post dated credit card transaction.
 “No Show” Appointment Fee: We reserve the right to charge a missed appointment fee to patients who do not show for a scheduled
surgery or office appointment. We require this fee to be paid before your next appointment.
 Finance Charge: A finance charge of one and a half percent (1 ½%) will be imposed on each item of your account which is overdue and
has not been paid within thirty (30) days.
Insurance Plans: It is ultimately your responsibility to know the details of coverage and network status of providers for your particular insurance
plan. However, as a courtesy, we will file all “In or Out of Network” insurance claims to the appropriate carrier. If your insurance company requires
a referral, you are responsible for obtaining it.
Contracted Insurance: (In Network): If we are contracted with your insurance company, we will submit claims for services provided. In order
for us to file your claim you must furnish us with all pertinent information along with your insurance card(s). It is the insurance company that makes
the final determination. If we are unable to verify your insurance information you will be responsible for the charges at the time of service.
Non-Contracted Insurance: (Out of Network): Patients who have insurance plans that do not have an existing contract with Urology
Center of Columbus, LLC are expected to pay in full at time of service.
Workers’ Compensation: We require written approval / authorization by your employer and / or workers’ compensation carrier prior to your initial
visit. If your claim is denied, you will be responsible for payment in full.
Account Statements: Statements are mailed out monthly to patients who have a balance due on their accounts. Payment of this balance is expected
on receipt of the statement. Any payment plans must be arranged with our billing department. Accounts overdue by more than 90 days may be
referred to a collection agency. We also have the right to report your account status to any credit reporting agency such as a credit bureau. By
signing this Financial Policy you give us permission to check your credit, employment history and answer questions about your credit experience
with us.
Authorized Signature: I authorize the release of any medical or other information necessary to process claims. I also request payment of
government benefits either to myself or the party who accepts assignment. I authorize payment of medical benefits to the undersigned physician or
supplier for all services.
Effective Date: Once you have signed this agreement, you agree to all of the terms and conditions contained herein and the agreement will be in full
force and effect.
Name: _____________________________________________________ DOB: ___________________________________

Signature: __________________________________________________ Date: __________________________________

Relationship Party (to the patient): __________________________________________

Revised 5/2015
 Prescribing Consent

Prescribing is defined as a physician’s ability to electronically send an accurate, error free and understandable
prescription directly to a pharmacy from the point of care. Congress has determined that the ability to
electronically send prescriptions is an important element in improving the quality of patient care. ePrescribing
greatly reduces medication errors and enhances patient safety. The Medicare Modernization Act (MMA) of
2003 listed standards that have to be includes in an ePrescribing program. These include:
 Formulary and benefit transactions – Gives the prescriber information about which drugs are covered
by the benefit plan.
 Medication status transaction – Provides the physician with information about medications the
patient is already taking to minimize the number of adverse drug events.
 Fill status notification – Allows the prescriber to receive an electronic notice from the pharmacy telling
them if the patient’s prescription has been picked up, not picked up or partially filled.

By signing this consent form you are agreeing that Urology Center of Columbus, LLC can request and use your
prescription medication history from other healthcare providers and/or third party pharmacy benefit payors for
treatment purposes.
Understanding all of the above, I hereby provide informed consent to Urology Center of Columbus, LLC to
enroll me in the ePrescribe Program.

____________________________________ ________________________
Patient Name Date of Birth

___________________________________ ________________________
Patient Signature Date

Relationship if not signed by patient________________________________________________

For Office Use Only

If written consent is not obtained, please check reason:

☐ Patient unable to sign

☐ Patient declined to sign

Revised 5/2015
 Male Patient History Form

Patient Name: __________________________________________ DOB: _____________ Acct #: ________

Name Prefer to be Called _____________________________________

Original Presenting Problem

This is a confidential document. Please fill out completely.

Please describe the main reason for your visit today. _________________________________________________
______________________________________________________________________________________________

1. Where is the problem located? Front Back Side Left Right Other _________________

2. How long has the problem existed? __ Days ___Week(s) ___ Month(s) More than 1 Yr

3. Does anything help the problem? Sitting/Standing Lying Down Pressure Heat/Cold
Other _______________________________________________________

4. How often does the problem occur? Daily (# of times___) Off & On Constant Infrequently

5. Are there other symptoms associated Fever/Chills Nausea/Vomiting Headache Difficult Urinating
with this problem? Other _______________________________________________________

6. Does this problem affect your daily life? No Yes; please describe: _________________________________
______________________________________________________________________________________________

Circle the number that best describes your problem: Severe ← 10 9 8 7 6 5 4 3 2 1 → Tolerable

7. Have you been treated for this condition in the past? No Yes; please explain________________________

_______________________________________________________________________________________________

Social History
Smoking History:
☐ Current every day smoker ☐Former Smoker
☐Never Smoked ☐ Unknown if ever smoked
☐Has never smoked or chewed tobacco ☐Currently uses smokeless tobacco

Do you drink alcohol? ☐ Yes ☐ No If yes, how many drinks per week? ______. For how long? ________

Revised 5/2015
Past Medical History
I have a history of... (Please check all that apply)
☐ Bladder Cancer ☐ High blood pressure
☐ Erectile Dysfunction ☐ High cholesterol/triglycerides
☐ Kidney Cancer ☐ HIV/Aids
☐ Kidney Stone ☐ Kidney Disease
☐ Kidney/Bladder Infection ☐ Liver Disease
☐ Low Testosterone ☐ Lung Disease
☐ Overactive Bladder ☐ Neurologic disorder
☐ Prostate Cancer ☐ Obesity
☐ Testicular Cancer ☐ Osteopenia
☐ Anemia ☐ Osteoporosis
☐ Bleeding Disorder ☐ Other Cancer What type?____________________
☐ Cataracts ☐ Psychological disorders
☐ Chronic Pain ☐ Sleep apnea
☐ Diabetes ☐ Spine, pelvic, or hip fracture
☐ Diverticulosis/diverticulitis ☐ Stomach ulcers/reflux/GERD
☐ Glaucoma ☐ Stroke
☐ Gout ☐ Thyroid
☐ Heart Disease ☐ No significant past medical history

Osteoporosis
Have you ever had a Bone Density Scan (DXA) to check for osteoporosis? ☐ Yes ☐ No

If yes, when? __________________________ Was it normal? ☐ Yes ☐ No

What doctor ordered the test? ____________________

Where was it performed? ____________________

Family History
My family has a history of... (Please check all that apply)
☐ Bladder Cancer If so, which relative: ___________________________________________________
☐ Kidney Cancer If so, which relative: ___________________________________________________
☐ Kidney Stones If so, which relative: ___________________________________________________
☐ Prostate Cancer If so, which relative: ___________________________________________________
☐ Testicular Cancer If so, which relative: ___________________________________________________
☐ Diabetes If so, which relative: ___________________________________________________
☐ Kidney Disease If so, which relative: ___________________________________________________
☐ Anemia If so, which relative: ___________________________________________________
☐ Bleeding Disorders If so, which relative: ___________________________________________________
☐ Other Cancer If so, what type? _________________________ which relative: ____________________
☐ Heart Disease If so, which relative: ___________________________________________________
☐ No significant family history
Revised 5/2015
AUA Questionnaire
Circle the answer that best describes your symptoms:
Not at all Less than Less than About More Almost
In the past month: 1 time in half the half the than half always
5 time time the time
How often have you had a sensation 0 1 2 3 4 5
of not emptying your bladder
completely?
How often did you urinate more than 0 1 2 3 4 5
once within a 2-hour period?
How often have you stopped and 0 1 2 3 4 5
started several times while urinating?
How often have you had difficulty 0 1 2 3 4 5
postponing urination?
How often have you had a weak 0 1 2 3 4 5
urinary stream?
How often did you strain to begin to 0 1 2 3 4 5
urinate?
How many times did you get up 0 1 2 3 4 5
during the night to urinate?
Total of the 7 circled answers above: ______________________

Mostly Mostly
Problem Delighted Pleased Satisfied Mixed Dissatisfied Unhappy Terrible
If you were to spend the rest
of your life with your urinary
condition just the way it is 0 1 2 3 4 5 6
now, how would you feel
about that?

SHIM Questionnaire
Circle the response that best describes your own situation.
Over the past six months:
1. How do you rate your confidence
that you could get and keep an Very Low Low Moderate High Very High
erection? 1 2 3 4 5
2. When you had erections with sexual A few times Most times
Almost (much less Sometimes (much more Almost
stimulation, how often were your than half the
erections hard enough for No sexual never or than half the (about half always or
time)
penetration (entering your partner)? activity never time) the time) always
4
0 1 2 3 5
3. During sexual intercourse, how A few times Most times
Did not Almost (much less Sometimes (much more Almost
often were you able to maintain
attempt never or than half the (about half than half the always or
your erection after you had time)
penetrated (entered) you partner? intercourse never time) the time) always
4
0 1 2 3 5
4. During sexual intercourse, how
difficult was it to maintain your Did not
erection to completion of attempt Extremely Slightly Not
intercourse? intercourse difficult Very difficult Difficult difficult difficult
0 1 2 3 4 5
5. When you attempted sexual A few times Most times
Did not Almost (much less Sometimes (much more Almost
intercourse, how often was it than half the
satisfactory for you? attempt never or than half the (about half always or
time)
intercourse never time) the time) always
4
0 1 2 3 5
Add the numbers corresponding to questions 1-5. Total __________
Revised 5/2015
Sexual History Questionnaire
Yes No Comment
1. Do you have what you consider a normal sexual drive and desire?
2. Do you have problems getting an erection?
3. Do you have problems maintaining an erection?
4. Does your erection last as long as you would like it to?
5. Does your erection last as long as your partner would like?
6. Do you have any problem with ejaculating or climaxing?
7. Do you ejaculate or climax too soon?
8. Are you able to get another erection soon after you ejaculate or climax?
9. Do you wake up at night or in the morning with an erection as often as
you used to?
If not, how long since you have? ______________________
10. Do you now or have you in the past, had a significant curvature of the
penis when you have a full erection (Peyronie’s disease)?
11. Has the firmness of your erections decreased?
12. Has it become more difficult to have intercourse in certain sexual
positions?
What percent of the time are you experiencing problems with sexual intercourse? %____________

Are the problems that you are experiencing affecting your relationship? Yes No
Was your erection problem first associated with:
Stress (job, financial, marital) Fatigue Argument or anger Fear or failure
A bad sexual encounter Depression Onset of an illness
A new medication A new partner Drugs or alcohol

ADAM Questionnaire

1. Do you have a decrease in sex drive? Yes No

2. Do you have a lack of energy? Yes No
3. Do you have a decrease in strength and/or endurance? Yes No
4. Have you lost height? Yes No
5. Have you noticed a decreased enjoyment of life? Yes No
6. Are you sad and/or grumpy? Yes No
7. Are your erections less strong? Yes No
8. During sexual intercourse, has it been more difficult to maintain
your erection to completion of intercourse? Yes No
9. Are you falling asleep after dinner? Yes No
10. Has there been a recent deterioration in your work performance? Yes No

Bowel Symptom Questionnaire

Which symptoms best describe you? Check all that apply.

☐ No bowel problems (if checked, please skip this questionnaire)
☐ Accidental loss or leakage of stool—sometimes unable to make it to the bathroom in time
☐ Bowel accidents while unaware—no warning and/or while asleep
☐ Frequent, loose, watery stools
☐ Sudden or strong urge to go to the bathroom
☐ Bowel accidents when passing gas

How long have you had these symptoms? __________________________________________

Revised 5/2015
 Approximately how many bowel incidents do you have per week? _______________________

Have you tried medications to help your symptoms? ☐ Yes ☐ No

On a scale of 0 to 10, with 0 being no symptom relief and 10 being complete symptom relief,
how much symptom relief have these medications provided for you? Circle number.

0 1 2 3 4 5 6 7 8 9 10

No Relief Complete Symptom Relief

Behavior modifications tried? ____________________________________________________

(e.g., lifestyle changes, fiber, diet changes, physical therapy)

On a scale of 0 to 10, with 0 being no frustration at all and 10 being extremely frustrated, what is
your level of frustration with your bowel control symptoms? Circle a number.

0 1 2 3 4 5 6 7 8 9 10

Not Frustrated Very Frustrated

Are you interested in learning more about additional treatment alternatives to bowel medications?
☐ Yes ☐ No

Review of Systems

Have you recently had problems with any of the following?….(Please check all that apply)
Genitourinary Eyes Gastrointestinal Hematologic/Lymphatic
Blood in urine Dry eyes Nausea/vomiting Easy bleeding or bruising
Cloudy urine Wear glasses or contacts Constipation EVER told you can’t donate
Frequent urination Difficulty swallowing blood
Strong urgency to urinate Diarrhea
Allergic
Burning/pain with urination Ear/Nose/Throat/Mouth Accidental leakage of stool
-have you EVER had a
Slow/weak stream
Dry mouth reaction to:
Waking up to urinate Musculoskeletal
Uncontrolled loss of urine Wears dentures Latex
Back pain
Pelvic Pain Sutures
Pain or difficulty with Neurological Anesthesia
Cardiovascular
intercourse Tape
Depression
Palpitations Iodine
Anxiety
Swelling in legs Contrast dye
Trouble sleeping
Pain in legs with walking If so what was the reaction?
Constitutional Symptoms
_________________________
Endocrine
Fatigue
Weight gain/ Obesity Flushing/hot flashes
I have not experienced
any of the above.

Patient Signature ______________________________________________ Date _______/________/________

Reviewed By __________________________________________________ Date ______/ ________/________

Physician Signature ____________________________________________ Date ______/________/________

Revised 5/2015