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Topics |
Forms |
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New Patient Forms to Complete
Please bring all applicable forms with you to your first
appointment. |
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| For All Patients to Complete: |
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| ¨ Patient Info |
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| ¨ Past
Medical & Family History |
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| ¨ Review
of Systems |
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| ¨ HIPAA
Privacy Form |
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For our Male
Patients to
Complete: |
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| ¨ AUA
BPH Symptom Score |
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| * Complete this form if you are a man over the age of 40 or if you are
experiencing symptoms like urinary frequency, urgency, or
hesitation. |
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| ¨ Sexual
Health Assessment |
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| * Complete this form if you are experiencing erectile dysfunction
(ED). |
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| ¨ Infertility
Questionnaire |
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| * Complete this questionnaire if you are trying unsuccessfully to
conceive a child. |
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For our Female Patients to
Complete: |
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| ¨ Incontinence
Questionnaire |
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| * Complete this questionnaire if you are experiencing urinary control
difficulties. |
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| ¨ Pelvic
Pain/Urinary Urgency Questionnaire |
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| * Complete this questionnaire if you are experiencing frequent,
urgent, and painful urination and pelvic discomfort. |
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| Surgery Scheduling |
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| About
Your Surgery - A General Guide |
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| Alexian
Brothers Ambulatory Care Instructions |
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| Drugs
Containing Aspirin |
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| Medical Records Requests |
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| Medical
Records Policy |
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| Medical
Records Release HIPAA Compliant |
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| Following Surgery or Diagnostic Procedure |
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| Post
Cystoscopy Instructions |
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| Post
Prostate Biopsy Instructions |
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| Post
Vasectomy Instructions |
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| Follow-up Recommendations |
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| Vasectomy
Follow-up Instructions |
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| Health Questionnaires |
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Infertility Questionnaire |
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Interstitial Cystitis Questionnaire |
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International Prostate Symptom Score |
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| Sexual
Health Assessment Questionnaire |
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| Voiding
Diary |
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| Test Preparation and Instructions |
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| Bladder
Ultrasound |
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| Prostate
Ultrasound and Biopsy Instructions |
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| Prostate
Ultrasound Instructions |
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| Residual
Scan and Uroflow Instructions |
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| Uroflow Instructions |
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| Drugs
Containing Aspirin |
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| Patient Education/Tools |
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Finasteride Study 2003 |
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Interstitial Cystitis Diet |
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* To save the forms to your hard disk, right click on
the icon and choose Save Target As...
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