PLEASE ARRIVE 15minutes PRIOR TO YOUR SCHEDULED APPOINTMENT TIME. Thank you!
Have you registered for our patient portal? This is a convenient way for you to make your next appointment without
calling the office, obtain test results and communicate with your physicians. All messages sent through the portal to your
physician are guaranteed to be answered within 24 business hours. Ask our staff about all the benefits of having your own
portal account.
Patient Registration
Last name:
Guardian**If Applicable
Middle name, suffix:
First Name:
First name:
Last Name:
Sex: Male or Female
Middle name, suffix:
SS#:
Emergency Contact
Address(ctd):
Relationship:
Date of Birth:
Address:
Name:
ZIP code:
Home Phone:
State:
Patient’s Care Team
City:
Home phone: ___________
Mobile phone:
Work phone:
Email:
Please  Contact preference:
Mobile Phone:
__________
Primary Care Physician: ______________________________
__________
Consent to call: Yes or No
Home Phone _____________
Work Phone ______________
Mobile Phone_____________
Pharmacies:
Referring Physician: ___________________________________
Employment
Employer Name:
Employer Phone:
_________
Occupation:
Local Pharmacy:
Mail order Pharmacy:
__________
Address:
Address:
Preferred Lab: _________________________________________________________________________________________________________________________________
Preferred Imaging Facility: __________________________________________________________________________________________________________________
Usual provider at Delaware Valley Urology:
Primary Language:
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Race:
Guarantor (name to whom statements are sent)
Marital status:
First Name:
Ethnicity:
Last Name:
How did you hear about us?
Middle name, suffix:
Date of Birth:
Patient’s relationship to guarantor:
Mailing address: [ ] ( if same as patient’s address)
Address:
Address:
City:
Zip:
State
Please indicate your health insurance coverage:
Primary Insurance: __________________________________
Subscriber Id #: ____________________________________________
Secondary Insurance: ________________________________
Subscriber ID#: _____________________________________________
Group Number: _____________________________________
Were you injured in a Motor Vehicle Accident?
Insurance Carrier:
________________________
Adjuster’s Phone#:
____________________________
Date of Injury:
Attorney’s Name:
Co-pay Amount: ________________
Y/N
____________________________
______________________________
Were you injured at work?
Y/N
Claim #: ________________________________________________________
Adjuster’s Name: ______________________________________________
Address: ________________________________________________________
Phone#:__________________________Fax#:_________________________
The above information is true to the best of my knowledge; I authorize my insurance benefits be paid directly to the
Physician/Practice. I understand that I am financially responsible for any balance. I also authorize Delaware Valley Urology, LLC.
(DVU) or my insurance company to release any information required to process my claims.
In accordance with Horizon BCBS Omnia Plan guidelines, we are required to inform you that DVU is a Tier 2 level practice with the
Horizon Omnia Plan. Tier 2 Omnia Plan benefits have higher deductibles and co-insurance levels for which you will be responsible.
Patient Name (please print): _______________________________________ Patient Signature: _________________________________________________
Guardian/Representative: ______________________________________________________________
For your convenience we can send your patient care summary directly to your portal account. If you have not registered
with us for a portal account please provide us with your email address.
Email: _____________________________________
HEALTH HISTORY
Problems
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Reason for today’s visit:
Onset: (date)
Allergies/Adverse Reactions
Drug/Allergen: _____
Drug/Allergen:
__________________ Reaction:
Date:
Reaction:
Date:
Reaction:
Drug/Allergen:
Family History
Relation:
Relation:
Surgical History
Procedure:
Date:
Problem:
Problem:
Onset age:
Onset age:
Age of death: ____
Age of death: ____
Surgery date:
Procedure:
Surgery date:
Procedure:
Surgery date:
Social History
Smoking Status: Never Smoker Former Smoker Current – Every Day Smoker  Current – Some Day Smoker 
Unknown if ever smoked
Smoking – How much?  None
Tobacco – years of use:
1PPD
2PPD
¼ PPD
½ PPD
 1 ½ PPD
Has smoked since age:
Alcohol intake: None Occasional Moderate Heavy Alcohol years of use:
Chewing Tobacco: None 1/day 2-4/day 5+day
Children:  Yes

2 PPD
3+PPD
No
Hobbies/Activities: _________________________________________ Caffeine intake: _____________________________
Occupation: ____________________________Illicit Drugs: None Marijuana Cocaine Heroin Ecstasy Inhalants
Other:______________________
Have you had a Colonoscopy? If yes date_____________________________________
Medications you currently take and the dosage. Please include all medications prescribed by a physician, over the
counter medications such as Tylenol and Motrin and all herbal medications
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Past Medical History - Please  all that apply
ADD/ADHD
Dementia/Alzheimer’s
disease
Hypothyroidism
(underactive thyroid)
Prostate cancer
Abnormal heart
rhythm/Atrial
fibrillation
Abscess
Depression
Infertility
Prostatitis
Diabetes
Interstitial Cystitis
Anemia
Dialysis
Angina (chest pain)
Diverticulosis/diverticulitis
Irritable bowel
syndrome
Kidney cancer
Anxiety
Arthritis
Asthma
BPH/enlarged prostate
Barrett’s Esophagus
Eating disorder
Elevated PSA
Endometriosis
Epilepsy (seizures)
Erectile dysfunction
Kidney Stone
Lung cancer
Lupus
MRSA infection
Migraine headaches
Bipolar disorder
Bladder cancer
Bladder Stones
Brain cancer
Breast cancer
COPD
(emphysema/chronic
bronchitis
Cataract
Cervical cancer or
Cervical Dysplasia
Chronic Pelvic Pain
Syndrome
Chronic back pain
Fibroids
Fibromyalgia
GERD/acid reflux
GI bleed
Gallstones
Gastritis/ulcers
Multiple Sclerosis
Obesity
Osteoporosis
Ovarian cancer
Ovarian cyst
PTSD
Pulmonary
embolism
Pulmonary
hypertension
Rheumatoid
arthritis
Schizophrenia
Sciatica
Seasonal allergies
Sepsis
Sexually
transmitted disease
(explain)
Skin cancer
Skin conditions
Sleep Apnea
Stomach cancer
Stroke/TIA
Syncope (fainting)
Glaucoma
Gout
Pancreatitis
Parkinson’s disease
HIV infection/AIDS
Pelvic Organ
Prolapse
Pelvic prolapse
Chronic kidney
disease
Colorectal cancer
Congestive heart
failure
Coronary artery
disease
Crohn’s disease
Hemorrhoids
DVT (blood clot)
Hyperthyroidism (overactive
thyroid)
Heart attack
Hepatitis
Herniated Disc
High cholesterol
Hydrocele
Peripheral vascular
disease
Peyronie’s Disease
Peripheral vascular
disease
Pneumonia
Polycystic ovary
syndrome
Testicular cancer
Tuberculosis/TB
Exposure
Ulcerative colitis
Urinary tract
infection
Uterine cancer
Vaginal cancer
Varicose veins
Vertigo
Vulvodynia
PATIENT HISTORY (OTHER) – Can you think of anything else about you that your physician may need to know?
Notes:
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Review of Systems
Please
circle
any issues that you CURRENTLY have
Constitutional:
fever | chills | weight gain (_____lbs) | weight loss (_____lbs) | trouble sleeping|
Eyes: dry eyes | double vision | eye pain | glaucoma | cataracts
Ear Nose Mouth Throat:
Ears: hearing loss | ringing in ears
Nose: frequent nosebleeds | nose problems |Hay Fever
Mouth/Throat: sore throat | dry mouth
Cardiovascular: chest pain | palpitations | leg swelling | leg pain with exercise | heart attacks
Respiratory: cough | wheezing | shortness of breath | coughing up blood | sleep apnea| asthma
Gastrointestinal:
abdominal pain | vomiting | change in appetite | black or tarry stools | frequent diarrhea | vomiting blood | dyspepsia | GERD
heart burn| constipation| difficulty swallowing| blood in stool| nausea/vomiting| change in bowel| diarrhea| jaundice| hiatal hernia| leakage of bowel
Genitourinary:
incontinence | difficulty urinating | visible blood in urine | frequency | change in stream | leakage with cough| leakage with urge| blood in urine| burning
pain| urgency| bathroom all night
Musculoskeletal :muscle aches | joint pain | back pain | sciatica pain
Integumentary: Skin: rash| dryness
Neurologic:Loss of consciousness|dizziness|numbness|headaches|tremor
Psychiatric: Stress|anxiety|depression|trouble sleeping|suicidal thoughts|feeling unsafe in your current living environment|memory loss
Endocrine: Fatigue|hot flash|excessive thirst|heat/cold intolerance|diabetes
Hematologic/Lymphatic: Swollen glands|easy bruising|excessive bleeding|blood clots
Allergic: runny nose|hives|frequent sneezing
Head/Neck: headache|head injury|pain|seizures at any time in life|stiffness
Breasts: lumps|pain|discharge|breast feeding
Last Mammogram: _________________________________
Genital:
pain with sex|heavy menses|itching or rash|history of ovarian cysts|interstitial cystitis|vaginal dryness|hot flashes|STDS|fibroids|discharge|endometriosis
Date of Last Pap Smear:
__________________________________
Vaccines:
Vaccine type:
__________________________________________
Date:
____________________________________
Have you had the flu shot this year? If yes, when?___________________________
Have you had the Pneumonia Vaccination? If yes, when? _____________________
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