*** Check List ***

  1. Please bring your insurance card(s) and picture ID.
  2. Fill out the registration forms.
  3. Bring a list of all your current medications.
  4. Bring in a copy of all your medical information and any imaging studies, (films or CD's).
  5. Call your referring doctor to have your records faxed to us prior to your appointment. Our fax number is (480) 963-6227, along with your referral if your insurance is an HMO.
  6. Be ready to leave a urine sample.
  7. Write down your addresses to your local and mail-in pharmacies.
  8. Hand carry in your registration forms, no need to mail.
  9. Please call 24 hours in advance to cancel your appointment; we reserve the right to charge for time reserved.
  10. We are located on the south side of Chandler Blvd.
  11. In the Regency Park Office Complex. Look for green metal roof tops. We are the last Bldg to your left as you drive into the main entrance. Address is 1455 W Chandler Blvd, Bldg. B Suite 8, chandler, AZ 85224. Our Phone number is 480-899-1696.We are between Alma School and Dobson Rd 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.

Urological Health Associates

Patient Name:

First

 M.I.

 Last
AGE
DATE (MM/DD/YYYY)
I have personally reviewed this form with the patient
Date (MM/DD/YYYY)
 Physician's Signature
How did you hear about this Office? (Print Name)

        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 Only:
Penile discharge
Erection Not hard enough for penetration (entering your partner)

Female Only:
Painful intercourse
Vaginal discharge
Vaginal abnormalities

Did you have any of the following problems 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
CARDIOVASCULAR SYSTEM:
Chest pain or tightness
Shortness of breath
Rapid or irregular heartbeats
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 breakdown
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 (MM/DD/YYYY)

Urological Health Associates
Medical History Questionnaire

*** All unanswered questions will be assumed to be NEGATIVE ***

ALL HEALTH PROBLEMS      none Since (MM/DD/YYYY) ALL HOSPITALIZATIONS       none Date (MM/DD/YYYY)
1)
1)
2)
2)
3)
3)
4)
4)
5)
5)
6)
6)
ALL INJURIES      none Date ALL SURGERIES      none Date
1)
1)
2)
2)
3)
3)
4)
4)
5)
5)
6)
6)

Local Pharmacy Name
  		 Local Address
  		 Pharmacy Phone (XXX) XXX-XXXX

Mail order Pharmacy
  		 Mail order Address
  		 Mail order Phone (XXX) XXX-XXXX

List all drugs you presently use regularly or take occasionally ALLERGIES
ALL MEDICATION      none Strength Dose No allergies known
Are you allergic to
Penicillin
Sulfa drugs
Codeine or Morphine
Latex
Latex Adhesive tape
Iodine (shellfish, contrast)		 List other allergies
1)
1)
2)
2)
3)
3)
4)
4)
5)
5)
6)
6)

Social History
Marital Status Tobacco Use Alcohol Use Drug Use
Single
Married
Divorced
Separated
Widowed		 Never
Quit years ago
Smoker
cigarettes daily
packs weekly
Never
Quit years ago
1-3 drinks daily
4-6 drinks weekly
> 6 drinks monthly
Never
Quit years ago
Marijuana
Cocaine
Other
Occupation

Family History
Relatives Alive / Health Died / Cause Age Is there family history of Residence-travel activity
Father












How long in AZ

Permanent Resident

Home town/area

Foreign travel

Activities

Hobbies

Mother
Brothers



Sisters



Sons



Daughters



First M.I. Last Age Date

*** NOTE : This form is for "Men only," everyone else please proceed to "Assignment of Benefits/Financial Policy" form. ***

Urology Care

FOUNDATION™
The Official Foundation of the American Urological Association

AMERICAN UROLOGICAL ASSOCIATION (AUA) SYMPTOM SCORE
First
M.I
Last
Date (MM/DD/YYYY)

Do you have any problem when you urinate? We recommend that you talk with health care provider if your total score on the first seven questions is 8 or greater or if you are bothered at all.

Have you notice any of the following when have gone to the bathroom to urinate over the past month? Circle the correct answer for you and write your score in the right-hand column.

Not at all Less then 1 time in 5 Less then half the time About half the time More then half the time Almost alwasy Your Score
Incomplete emptying -- It does not feel like i empty my bladder all the way.
Frequency -- I have to go again less than two hours after I finish urinating.
Intermittency -- I stop and starts again several times when urinate.
Urgency -- It is hard to wait when I have to urinate.
Weak stream -- I have a week urinary stream.
Straining -- I have to push or strain to begin urination.
None 1 time 2 time 3 time 4 time 5 time Your Score
Nocturia -- I get up to urinate after I go to bed until the time I get up in the morning.
Total AUA Symptom Score    
Total score: 0-7 mild symptoms; 8-19 moderate symptoms; 10-35 severe symptoms    
Quality of life due to urinary symptoms
If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that?



National Headquarters: 1000 Corporate Boulevard, Linthicum, MD 21090
Phone: 410-689-3990 . Fax: 410-689-3878 . 1-800-828-7866
info@UrologyCareFoundation.org . www.UrologyHealth.org



Appendix:
The Sexual Health Inventory for Men(SHIM) or IIEF-5

Over the past 6 months,

Your Score
1. How did you rate your confidence that you could get & keep an erection? Very Low
 Low
Moderate
 High
 Very high
2. When you hade erections with sexual stimulation, how often were your erections hard enough for penetration? No sexual Activity
 Almost Never or Never
 A few times
 Sometimes
 Most times
 Almost always or always
3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated your partner? Did not attempt Intercourse
 Almost Never or Never
 A few times
 Sometimes
 Most times
 Almost always or always
4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? Did not attempt Intercourse
 Extremely Difficult
 Very Difficult
 Difficult
 Slightly difficult
 Not Difficult
5. When you attempted sexual intercourse, how often was it satisfactory to you? Did not attempt Intercourse
 Almost Never or Never
 A few times
 Sometimes
 Most times
 Almost always or always
SHIM Total    

The IIEF-5 is administered as a screening instrument for the presence & severity of ED in conjunction with the clinical assessment. The score is the sum of the responses to five items, so that overall score may range from 1 to 25. A score of 20 or heigher indicates a normal degree of erecttile functioning. Low scores(10 or less) indicate moderate to severe ED.

Please fill out completely:

Ironwood Physicians DBA Ironwood Cancer & Research Centers; Ironwood Radiology

ASSIGNMENT OF BENEFITS / FINANCIAL POLICY

Patient Name:

First
  		M.I.

  		Last

  		Home Telephone (XXX) XXX-XXXX

House Address:

Cell number
City
State
Zip
Permanent Resident State
Date of Birth (MM/DD/YYYY) Age

 
  		Sex

 
  		SSN (XXX-XX-XXXX)
Marital Status

 
 

Employer:

Name Address Phone
(XXX) XXX-XXXX
Are you currently working? Retired Disabled

Responsible Party:

Name
Relationship
Telephone (XXX) XXX-XXXX

Other than Patient:

Address
State
Zip code

Who referred you to us?
 Name
Phone (XXX) XXX-XXXX

Primary Ins
   		Telephone (XXX) XXX-XXXX
Insured Name
   		DOB (MM/DD/YYYY)
Group#
   		Policy#
  
Secondary Ins
   		Telephone (XXX) XXX-XXXX
Insured Name
   		DOB (MM/DD/YYYY)
Group#
   		Policy#
  

  1. I understand that I am responsible for charges not covered or reimbursed by the above insurances. I will inform the billing dept. of any change in insurance coverage. I understand that I may be responsible for charges if correct insurance is not provided and billed timely. I agree, in the event of non-payment, to assume the costs of interest, collection and legal action (if required).
  2. I authorize my insurance carrier to release information regarding my coverage to Ironwood Cancer & Research Centers billing dept.
  3. My right to payment for all pharmaceuticals, procedures, tests, medical equipment rentals, supplies and nursing/physician services including major medical benefits are hereby assigned to Ironwood Cancer & Research Centers. This assignment covers any and all benefits under Medicare, other government sponsored programs, private insurance and any other health plans.
  4. I acknowledge this document as a legally binding assignment to collect my benefits as payment of claims for services. In the event my insurance carrier does not accept Assignment of Benefits, or if payments are made directly to me or my representative, I will endorse such payments to Ironwood Cancer & Research Centers. I understand that Ironwood Cancer & Research Centers will collect any coinsurance amounts that I owe at time of service. This assignment will remain valid until revoked by me in writing.
  5. I understand that I have a right to request and receive a Notice of Privacy Practices from Ironwood Cancer & Research Centers.
  6. I authorize my insurance carrier to release information regarding my coverage to Ironwood Cancer & Research Centers.
THIS AGREEMENT/CONSENT WILL REMAIN IN EFFECT UNLESS REVOKED BY ME IN WRITING.
I have read and received a copy of the above statements and accept the terms. A duplicate of the statement is considered the same as original.


Patient Signature (Electronic)/Responsible Party
Date (MM/DD/YYYY)

Ironwood Cancer & Research Centers
Consent to Release Health Information

Patient Name:

First
M.I.
 Last
Date (MM/DD/YYYY)
I hereby authorize Ironwood Cancer & Research Centers and Urology Associates to use and disclose my personal health information to the individuals identified on this form. Initials
I approve and understand that the staff at Ironwood may leave detailed messages on my voicemail. Initials

Emergency Contacts:

Contact Name:

First

  		 M.I.

  		 Last

  		 Telephone (XXX) XXX-XXXX
Address
City

 State
 Zip
Relation Emergency Contact?

Contact Name:

First

  		 M.I.

  		 Last

  		 Telephone (XXX) XXX-XXXX
Address
City

 State
 Zip
Relation Emergency Contact?

Contact Name:

First

  		 M.I.

  		 Last

  		 Telephone (XXX) XXX-XXXX
Address
City

 State
 Zip
Relation Emergency Contact?
  1. I hereby authorize Ironwood Cancer & Research Centers and Urology Associates to use and disclose my personal health information to the individuals identified on this form.
  2. I understand this may include information relating to communicable diseases, such as HIV/AIDS, STD, behavioral, and/or mental health, alcohol and/or drug abuse treatment, and genetic testing information, if any records exist.
  3. I understand that the individuals identified on this form will be treated by Ironwood Cancer & Research Centers and Urology Associates as individuals involved directly in my care and as such Ironwood Cancer & Research Centers and Urology Associates will be allowed to release my personal health information to these individuals for the purposes of treatment, payment and healthcare operations.
  4. I understand that I have a right to request and receive a Notices of Privacy Practices from Ironwood Cancer & Research Centers and Urology Associates.
THIS AGREEMENT/CONSENT WILL REMAIN IN EFFECT UNLESS REVOKED BY ME IN WRITING.

I have read and received a copy of the above statements and accept the terms. A duplicate of the statement is considered the same as original. I voluntarily sign this authorization, and I understand that my ability to obtain health care from Ironwood Cancer & Research Centers and Urology Associates will not be affected if I refuse to sign this authorization.


Patient Signature (Electronic) 		Date/Time (MM/DD/YYYY)

Personal Representative Signature (Electronic)
Relationship		 Date/Time (MM/DD/YYYY)