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Available Forms

Current Patient Questionnaire

Patient Demographics

 

Pharmacy Info

 

Insurance Info ( Please Bring Insurance Card to Visit)

 

Would you like us to communicate with you by Email

***Physical signature will be required upon office visit.***

Receipt of Privacy Practices (HIPPA)

I have received a copy of Rebecca Kurth, MD's Notice of Privacy Practices

***Physical signature will be required upon office visit.***

Patient Questionnaire

Please list other physicians, specialists and/or health care providers you consult with on a regular basis
Please list medications, including dosage, which you are taking on a regular basis
Please list all vitamins, supplements and/or over-the-counter medications, including dosage, which you are currently taking
Please specify
 

Social Background

If yes, how much and how long?
If yes, how much do you consume?
 

Family Background

Please note any changes in health status of the following:

 

General Review

If yes, please specify
 

Please check any of the following symptoms that you may be experiencing:

Pain In
Swelling In
 

Men - Urinary System

If yes, please specify:
 

Women - Urinary System

If yes, how many times?
If yes, please specify:
 

Travel

please state where you are going, when you are leaving, and for how long?
 

Exam Dates

* Required field