Contact Urologic Health Associates Today At
480-899-1696 to schedule an appointment
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ChickList

Checklist
  • Please bring your insurance cards and picture ID.
  • Fill out the registration forms.
  • Bring a list of all your current medications.
  • Bring in a copy of all your medical information and any imaging studies, (films or CD's).
  • Call your referring Dr to have your records faxed to us prior to your appointment. Our fax # is (480)963-6227 , along with your referral if your insurance is a HMO.
  • Be ready to leave a urine sample.
  • Write down your addresses to your local and mail in pharmacy's.
  • Hand carry in your registration forms, no need to mail.
  • Please call 24 hours in advance to cancel your appt., we reserve the right to charge for time reserved.
  • We are located on the south side of Chandler Blvd.
  • In the Regency Park Office Complex. Look for green metal roof tops. We are the last Bldg to your left as drive into the main entrance. Address is 1455 W Chandler Blvd Bldg B Suite 8 chandler, Az 85224. Our Phone # is 480-899-1696.We are between Alma Sch. and Dobson on the South side of the road.
Marlou Heiland, MD; and Anthony Dyer,MD; Urologic Health Associates, a Division of Ironwood Cancer and Research Centers.

Step 1 Patient Demographic

Patient Demographic
First Name : Last Name : Date of birth :
Who did you hear about us ? Name:
Have you ever had any of the following?
Blood in the urine Kidney stones Infection of bladder or kidney
In the last year have you had incontinence of urine?
Use of pads per day
In the last year have you had voiding problems?
Pain and discomfort while urinating Burning with urination Incomplete bladder emptying
Delay in starting urination Weak urinary stream : Straining with urination
Stream starts and stops repeatedly
Do you have problem with your sexual life?
Diminished sexual drive Loss of sexual arousal
Male Onle:
Penile discharge Erection Not hard enough for penetration (entring your partner)
Female Onle:
Painful intercourse Vaginal discharge Vaginal abnormalities
Do you had any of the following problem in the last year?
GENERAL:
Excessive fatigue Vaginal abnormalities Chills or fever
EYES:
Changes in your vision Double or blurred vision Glaucoma
Cataract Classes or contact lenses
EARS , NOSE AND THROAT :
Hearing loss Hearing aid Nose bleeds
Running nose (rhinitis) Blocked sinuses Frequent colds and sore throat
GARDIOVASCULAR SYSTEM :
Chest pain or tightness Shortness of breath Rapid or irregular heart beats
High blood pressure Foot and ankle swelling Leg distress while walking
Varicose veins
RESPIRATORY SYSTEM :
Wheezing or asthma Chronic persistent cough Coughing of blood
Pneumonia
DIGESTIVE TRACT :
Loss of appetite Nausea Vomiting
Heartburn Indigestion Gas or bloating
Constipation Diarrhea Black or bloody bowel movements
Hemorrhoids
MUSCLE, BONES & JOINTS :
Joint pain Back pain Muscle ache
Muscle weakness Broken bones
SKIN :
Itching of skin Skin rash Boils
Non healing sores Jaundice (yellow skin, eyeballs) Dry skin and hair
LYMPHATIC & HEMATOLOGICAL :
Anemia Easy bruising or bleeding Blood clot in your legs or lungs
Enlarged lymph glands Blood transfusion Cortisone medication
NEUROLOGICAL :
Trouble Sleeping Trembling hands Numbness or tingling
Shooting pains Black out spells Dizziness
Seizures
PSYCHIATRIC :
Worries and fears Depressed feelings Tension at home or work
Nervous break down Psychiatric care or treatment
ENDOCRINE SYSTEM :
Excessive thirst Feeling colder than others Feeling warmer than others
Diabetes Thyroid dysfunction
OBSTETRICAL HISTORY :
Pregnancies Childbirths Miscarriage
Menopause Hysterectomy Menstruating
Date last menstrual period began

Step 2 History

Patient Information
Gender :
MI : MRN :
Street 1 : Street 2:
Country : State :
PR State : City :
Zip Code : SSN (XXX-XX-XXXX):
Phone No : Mobile No :
Referred By : Referee Name :
Referee Phone : Marital Status :
Employer Name : Employer address :
Employer Phone : Tobacco Use :
Tobacco Usege : Alcohol Use :
Alcohol Usege : Drug Use :
Occupation :

Family History

Step 3 Health,Injuries,Hospitalication,Surgeries

All Health Problems
Health Problem Since
All Injuries
Injury Injury Date
All Hospitalization
Hospitalization Hospitalization Date
All Surgeries
Surgery Surgery Date

Step 4 Content

All Medication
Medication
Strength Dose
All Allergies
Allergy
Family
Relative Alive
Cause Age
Contacts
First Name Last Name
MI Phone
Address Country
State City
Zip Code Relation
Emergency Contact
  
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