! !

Hackensack(University(Medical(Group(|(Urology(360(Essex(Street,(Suite(403(((Ι(((Hackensack,(NJ(07601(((Ι(((551F996F8090((((Ι((((www.urologynj.com(

IHOR!S.!SAWCZUK,!M.D.,!F.A.C.S.!• Professor & Chairman • Chief, Urologic Oncology John Theurer Cancer Center • Executive VP & Chief Medical Officer

RAVI!MUNVER,!M.D.,!F.A.C.S.!• Associate Professor & Vice Chairman • Chief, Minimally Invasive & Robotic Urologic Surgery • Urologic Oncology & Kidney Stones !KEVIN!R.!BASRALIAN,!M.D.,!F.A.C.S.!• Attending MICHAEL!DEGEN,!M.D.!• Clinical Assistant !DEBRA!FROMER,!M.D. • Assistant Professor • Chief, Center for Bladder, Prostate & Pelvic Floor Health MICHELLE!KIM,!M.D. • Assistant Professor • Chief, Prostatic Disorders and Pelvic Tumors HARRY!P.!KOO,!M.D.,!F.A.A.P.,!F.A.C.S. • Professor • Chief, Pediatric Urology DAVID!SHIN,!M.D. • Assistant Professor • Chief, Center for Sexual Health & Fertility •Men’s Health RICHARD!WATSON,!M.D.,!F.A.C.S. • Professor • Chief, Ambulatory Urology ALAN!N.!!LEIPSNER,!MPH,!MBA,!FACHE!• Administrative Director Urology Academic Affairs Medical Library !!!!!

Dear(Patient,((Thank(you(for(choosing(Hackensack(University(Medical(Group(|(Urology.((We(look(forward(to(meeting(you(and(providing(you(with(the(highest(quality(urological(care.((In(addition(to(our(physicians,(nurses(and(clinical(assistants,(who(will(look(after(your(medical(needs;(our(administrative(staff(is(here(to(help(you(with(scheduling,(billing,(and(other(nonFclinical(issues.((Please(take(a(few(minutes,(prior(to(your(first(visit,(to(complete(and(review(the(following(information(related(to(our(practice.((Doing(so,(will(enable(us(to(serve(you(as(efficiently(as(possible.((

Office&hours&by&appointment&To&schedule&an&appointment&please&call&(551)&996<8090&

&(Included(in(this(packet(for(your(review(and(completion(are(the(following:(

• Registration(Form(• New(Patient(Information(Form(• Questionnaire(s)(• Directions(&(Map(

(In(addition,(we(ask(that(you(bring(the(following(to(your(appointment:(

• Completed(Forms(• Drivers(license(or(legal(form(of(picture(ID(• Insurance(Card(• Insurance(coFpay(• List(of(medications(and(allergies(• Any(and(all(radiology(films(&(reports(–(Please(provide(any(radiology(images((e.g.(XFRay,(

MRI,(Cat(Scan,(and/or(Ultrasound),(or(study(results(relating(to(your(visit((While(under(the(care(of(our(physicians(if(you(need(to(renew(a(prescription,(please(call(your(pharmacy(or(fill(out(the(online(prescription(renewal(form,(found(on(our(website,(urologynj.com.((Please(note(HackensackUMG(|Urology(has(a(noFshow(policy.((Kindly(cancel(or(reschedule(your(appointment(at(least(24(hours(in(advance.((If(a(patient(is(scheduled(for(an(appointment(and(does(not(cancel(or(reschedule,(a(letter(will(be(sent(to(the(patient(charging(them($25.((For(billing(questions(contact(your(billing(representative(within(the(department(at(551F996F8626.((For(all(billing(inquiries(and(details(on(your(statement(please(contact(HackensackUMG’s(Billing(Office(at((866)(571F9238.((Our(goal(is(to(provide(you(with(exceptional(service(and(state(of(the(art(patientFcentered(medical(care(in(an(environment(that(is(sensitive(to(your(needs.((Please(let(us(know(how(we(are(doing(or(how(we(may(improve(our(service(and(do(not(hesitate(to(call(us(if(you(have(any(questions.((Thank(you(again(for(choosing(HackensackUMG(|(Urology(and(we(look(forward(to(meeting(you.(

!

Patient!Information!

!

Date:&____________________________& SSN#:&________________________&

Last&Name:&_______________________& First&Name:&____________________&

Date&of&Birth:&______________________& Gender:& &Male& &&&&&&&Female&

Address:&_________________________________________________________&

City:&____________________________& State:&_______& Zip:&___________&

Special&Living&Arrangements:! &�&None&&&&&&&�&Assisted&Living&&&&&�&Nursing&Home&

Home&Phone:&_____________________& Cell&Phone:&____________________&

EFmail&Address:&___________________________________________________&

Race:& American&Indian/Alaska&Native& Asian& African&American/Black&& Native&Hawaiian/Pacific&Islander& White/Caucasian& &Ethnicity:& Central/South&American& Cuban& Mexican& Puerto&Rican&& Other&Hispanic/Latino& NonFHispanic/Latino&

Preferred&Language:&________________& Marital&Status:!_________________&

Employment:!�&Employed&&�&Medical&Disability&�&SelfFEmployed&&�&Retired&&�&Unemployed&

Employer:&____________________&Employer&Address:&___________________&

Emergency&Contact:&_____________________&Relation:&__________________!

Address:&______________________________&Phone&#&___________________!

Pharmacy&Name:&________________________&Phone&#&__________________&

How&did&you&hear&about&us:&__________________________________________&

Primary!Physician!Information!

NAME:!__________________________________________________________&

ADDRESS:!______________________________________________________&

PHONE!#:!_______________________________________________________&

&

_____________________________________& &&&&&&&&&&_________________&Patient’s&Signature& & & & & & Date&

!

!

Insurance!Information!

Primary!Insurance!

Name&of&Policy&Holder/Guarantor:&_______________________&DOB:&________&

Relationship&to&Patient:&______________________&SSN#:&_________________&

Policy&Holder/Guarantor’s&Address:&____________________________________&

Status:&!Employed&&&&Medical&Disability&&&&&&&&&&&SelfFEmployed&&&&&&&&&&&&&Retired&&&&&&&&&&&&Unemployed&

Employer:&____________________&Employer&Address:&__________________&

Insurance&Company:&_______________________________________________&

Insured’s&Policy/&ID&#:&____________________&Group&#:&__________________&

Insurance&Co.&Address:&_______________________&Phone&#:&______________&

&&&&&&&&&&&&Name&of&Lab&Determined&by&Insurance:&______________________________________&

FFFFFFFFFFFFFF&DO&YOU&HAVE&ANY&ADDITIONAL&INSURANCE?&&&Yes&&&No&FFFFFFFFFFFFFF&

IF&YES,&PLEASE&COMPLETE&THE&FOLLOWING:&

Secondary!Insurance!

Name&of&Policy&Holder/Guarantor:&_______________________&DOB:&________&

Relationship&to&Patient:&______________________&SSN#:&_________________&

Policy&Holder/Guarantor’s&Address:&____________________________________&

Status:!�&Employed&&�&Medical&Disability&�&SelfFEmployed&&�&Retired&&�&Unemployed&

Employer:&____________________&Employer&Address:&__________________&

Insurance&Company&Address:&________________________________________&

Insured’s&Policy/&ID&#:&____________________&Group&#:&__________________&

Insurance&Co.&Address:&_______________________&Phone&#:&______________&

&

PLEASE&PROVIDE&INSURANCE&CARDS&AND&PICTURE&ID&TO&FRONT&DESK&

MAKE&CHECKS&PAYABLE&TO&“HUMG”&

International Prostate Symptom Score (IPSS) Name: Date:

Not

at a

ll

Less

than

1

time

in 5

Less

than

ha

lf th

e tim

e A

bout

hal

f th

e tim

e

Mor

e th

an

half

the

time

Alm

ost

alw

ays

You

r sc

ore

Incomplete emptying Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating?

0 1 2 3 4 5

Frequency Over the past month, how often have you had to urinate again less than two hours after you finished urinating?

0 1 2 3 4 5

Intermittency Over the past month, how often have you found you stopped and started again several times when you urinated?

0 1 2 3 4 5

Urgency Over the last month, how difficult have you found it to postpone urination?

0 1 2 3 4 5

Weak stream Over the past month, how often have you had a weak urinary stream?

0 1 2 3 4 5

Straining Over the past month, how often have you had to push or strain to begin urination?

0 1 2 3 4 5

Non

e

1 tim

e

2 tim

es

3 tim

es

4 tim

es

5 tim

es o

r m

ore

You

r sc

ore

Nocturia Over the past month, many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning?

0 1 2 3 4 5

Total IPSS score

Quality of life due to urinary symptoms D

elig

hted

Plea

sed

Mos

tly

satis

fied

Mix

ed –

ab

out e

qual

ly

satis

fied

and

diss

atis

fied

Mos

tly

diss

atis

fied

Unh

appy

Terr

ible

If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that? 0 1 2 3 4 5 6

Total score: 0-7 Mildly symptomatic; 8-19 moderately symptomatic; 20-35 severely symptomatic.

International Index of Erectile Function (IIEF) Questionnaire Please circle the appropriate numbers below

Patient Name _______________________________________ Today’s  Date  ___________________________

1. How often were you able to get an erection during sexual activity?

0 no sexual activity

1 almost never

2 a few times

3 sometimes

4 most times

5 almost always

2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration?

0 no sexual activity

1 almost never

2 a few times

3 sometimes

4 most times

5 almost always

3. When you attempted sexual intercourse, how often were you able to penetrate (enter) your partner?

0 did not attempt

intercourse

1 almost never

2 a few times

3 sometimes

4 most times

5 almost always

4. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?

0 did not attempt

intercourse

1 almost never

2 a few times

3 sometimes

4 most times

5 almost always

5. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?

0 did not attempt

intercourse

1 extremely difficult

2 very difficult

3 difficult

4 slightly difficult

5 not

difficult

6. How many times have you attempted sexual intercourse?

0 no attempts

1 one to two attempts

2 three to four

attempts

3 five to six attempts

4 seven to ten

attempts

5 eleven + attempts

7. When you attempted sexual intercourse, how often was it satisfactory?

0 did not attempt

intercourse

1 almost never

2 a few times

3 sometimes

4 most times

5 almost always

8. How much have you enjoyed sexual intercourse?

0 no intercourse

1 no

enjoyment

2 not very

enjoyable

3 fairly

enjoyable

4 highly

enjoyable

5 very highly enjoyable

9. When you had sexual stimulation or intercourse, how often did you ejaculate?

0 no sexual

stimulation/ intercourse

1 almost never

2 a few times

3 sometimes

4 most times

5 almost always

10. When you had sexual stimulation or intercourse, how often did you have the feeling of orgasm or climax?

0 no sexual

stimulation/ intercourse

1 almost never

2 a few times

3 sometimes

4 most times

5 almost always

11. How often have you felt sexual desire?

1 almost never

2 a few times

3 sometimes

4 most times

5 almost always

12. How would you rate your level of sexual desire?

1 very low/ none at all

2 low

3 moderate

4 high

5 very high

13. How satisfied have you been with your overall sex life?

1 very

dissatisfied

2 moderately dissatisfied

3 about equally satisfied and dissatisfied

4 moderately

satisfied

5 very

satisfied

14. How satisfied have you been with your sexual relationship with your partner?

1 very

dissatisfied

2 moderately dissatisfied

3 about equally satisfied and dissatisfied

4 moderately

satisfied

5 very

satisfied

15. How do you rate your confidence that you could get and keep an erection?

1 very low

2 low

3 moderate

4 high

5 very high

SHIM: 2, 4, 5, 7, 15: ___________

Revised 3/21/2013

Alfred Sanzari Medical Arts Building 360 Essex Street, Suite 403

Hackensack, NJ 07601 551-996-8090

Directions from Paterson Area and West Follow Route 80 East, staying in local lanes to Exit 63B for Rochelle Park and Paramus. (Exit ramp sign says Exit 63). Turn left off exit ramp and turn right at light onto Essex Street. Follow Hospital signs. At fifth light, turn left onto Summit Avenue. Turn immediate right onto Thompson Street to access our underground parking garage. Take the elevators to the 4th floor.

From George Washington Bridge East Follow Route 80 West, staying in local lanes, to Exit 64B. Turn right at light onto Polifly Road. Travel north on Polifly Road. At second light, turn left onto Essex Street. At first light, turn right onto Prospect Avenue. Make an immediate left onto Thompson Street to access our underground parking garage. Take the elevators to the 4th floor. From Southern New Jersey via the New Jersey Turnpike Follow Route 95-N.J. Turnpike North to the junction of Route 80. Take 80 West and stay in lanes for "Local Exits" to exit 64B for Hasbrouck Heights and Newark. Turn right at light onto Polifly Road. Travel north on Polifly Road. At second light, turn left onto Essex Street. At first light, turn right onto Prospect Avenue. Make an immediate left onto Thompson Street to access our underground parking garage. Take the elevators to the 4th floor. From Northern New Jersey on Route 17 Follow Route 17 South to Essex Street exit. Turn left onto Essex Street. At fourth light, turn left onto Summit Avenue. Turn immediate right onto Thompson Street to access our underground parking garage. Take the elevators to the 4th floor. From Southern New Jersey on Route 17 Follow Route 17 North to Polifly Road turnoff. Go under the Route 80 overpass and turn left at the second light onto Essex Street. At first light, turn right onto Prospect Avenue. Make an immediate left onto Thompson Street to access our underground parking garage. Take the elevators to the 4th floor.

From the Lincoln Tunnel Take Route 3 West to Route 17 North to Essex Street exit. Turn right onto Essex Street. At second light, turn left onto Summit Avenue. Turn immediate right onto Thompson Street to access our underground parking garage. Take the elevators to the 4th floor.

From the Garden State Parkway From the Garden State Parkway, either north or south, take Route 80 East. Follow directions above for Paterson Area and West.

HBF #5005787 Rev. 2/2012

Hackensack University Medical Center Campus Map