Welcome to the Urology Center of Florida. We are committed to providing you with the best and most experienced leading-edge care. You will find that our staff is friendly and helpful and your diagnosis and treatment will be done in a confidential and comfortable setting. Please fill this form out COMPLETELY so we may best be able to provide excellent service to you.
Chief Complaint: (Reason for visit, describe in detail including duration of problem)
List all past and present medical conditions and surgeries with dates:
List all prescription and non prescription medications, including herbal preparations. Please include dosages and your local PHARMACY with phone number if you have one. If necessary, we may serve you better by calling in your prescriptions if the need arises. Also, please indicate if you take Coumadin, Aspirin, Plavix, or Vitamin E.
List all allergies to medications and describe the type of reaction as well as the year the reaction occurred.
Are you on a special diet?
If yes, please describe.
Do you smoke?
If yes, how much?
Do you drink?
Do you require antibiotic prophylaxis before going to the dentist?
Do you require a wheelchair, walker, or cane?
Do you have a pacemaker or defibrillator?
Double or Blurred Vision
Shortness of Breath
Stroke or TIA
Too Hot/Too Cold
High Blood Pressure
Mitral Valve Prolapse or Valvular Disease
Skin Rash of Persistent Itching
Blood Clotting Problems
Are you satisfied with your life?
Do you feel SEVERLY depressed?
Have you considered suicide?
Sexually Transmitted Diseases