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Valley Urology
6113 N. Fresno St.
Suite #101
Fresno, CA 93710
Ph (559) 438-2777
Fax (559) 438-4117

Please call for an Appointment

For new patients, please download and fill-out by hand the blank PDF patient forms, or type and then print them out using the online template  
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Patient History Form
  Name :
  Date :
Chief Complaint :
How long has this problem been present ?
Have recent tests been performed for this problem
(X-rays, Urine culture, Blood tests)
What facility were these tests
performed at?
Past Medical And Social History :
Do you currently smoke ?
yes
How many packs ? How many years ?
Have you ever smoked ?
yes

No
How many packs ? How many years ?
Have you ever quit smoking ?
yes

No
For how long?
Marital Status Single Married      Widow       Divorced
Children
yes

No
How many ?
Do you drink alcohol ? Never Rarely      Moderately       Heavy
Occupation?
Allergies to Medications and Reactions:
Current prescription medicines you take on a regular basis:
List and date any previous surgeries you have had:
Does anyone in your immediate family have ? (Please select)
Diabetes Bladder Cancer Tuberculosis
High Blood Pressure Prostate Cancer Heart Disease
Kidney Stones Colon / Rectal Cancer Other :
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6113 N. Fresno St. Suite #101 Fresno, CA 93710 Ph: (559)438-2777, Fax: (559)438-4117 www.ValleyUrology.com