Urology Specialists, S.C. - Patient History Form

PATIENT HISTORY FORM

TODAY'S DATE_____/_____/_________

DATE OF BIRTH_____/_____/________

LAST NAME_______________________

FIRST NAME___________________

MIDDLE________

History of Present Illness

Reason for this visit_________________________________________________________________________
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Duration of above complaint Please indicate number ______ week(s) ______ month(s) ______ year(s)

Have you been treated for this condition in the past? Yes No If yes, please explain______________
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Frequency of urination Daytime___ Nighttime___ Strength of stream Normal___ Decreased___ Poor___

Are you experiencing any of the following symptoms? Please circle Yes or No

			Comments				Comments
Blood in urine	Y	N	_________________	Leakage of urine	Y	N	_________________
Urinary infections	Y	N	_________________	Interruption of urinary stream	Y	N	_________________
Kidney or bladder stones	Y	N	_________________	Split stream	Y	N	_________________
Urgent urination	Y	N	_________________	Burning or discomfort with urination	Y	N	_________________
Dribbling after voiding	Y	N	_________________	Hesitancy in initiating stream	Y	N	_________________
Recent X-Rays	Y	N	If yes, what type of x-rays were performed and where?
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Physician use only:

Past Medical History and Social History

List any personal serious illnesses or surgeries you have had and when they occurred in chronological order with approximate dates.
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List all serious illnesses in your immediate family. (Example: diabetes, cancer, heart disease, elevated cholesterol, hypertension, etc.)
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Are you currently taking any prescription or non-prescription medications? (Example: aspirin; ibuprofen; hormone replacements; dietary, herbal, or vitamin supplements) Yes No If yes, list all.
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Do you have any allergies to medications, Latex, iodine contrast, or adhesives? Yes No If yes, list all.
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Have you ever had a blood transfusion? Yes No If yes, when?______________________________________

Do you currently smoke? Yes No If yes, how many packs/day?__________ For how many years?________

Do you currently drink alcoholic beverages? Yes No

If yes, how much and how often?_______________________ For how many years?_______________________

If you have a prior history of drinking, when did you stop?____________________________________________

Physician use only:

Review of Systems
Do now or have you ever had any of the following problems? Circle Yes or No.

Constitutional Symptoms			Musculoskeletal
Fever	Yes	No	Joint Pain	Yes	No
Chills	Yes	No	Neck Pain	Yes	No
Other _____________________________			Back Pain	Yes	No
			Other __________________________________
Eyes
Blurred vision	Yes	No	Integumentary
Double vision	Yes	No	History of jaundice	Yes	No
Pain	Yes	No	Skin rash	Yes	No
Other _____________________________			Boils	Yes	No
			Persistent itch	Yes	No
Ears/Nose/Throat/Mouth			Other __________________________________
Ear infection	Yes	No
Hearing aid	Yes	No	Gastrointestinal
Sore throat	Yes	No	Abdominal pain	Yes	No
Hoarseness	Yes	No	Indigestion / heartburn	Yes	No
Change in swallowing	Yes	No	Nausea / vomiting	Yes	No
Sinus problems	Yes	No	Diarrhea	Yes	No
Other _____________________________			Constipation	Yes	No
			Blood in stool / black stool	Yes	No
Cardiovascular			History of ulcer	Yes	No
Chest pain	Yes	No	Other __________________________________
Heart palpitations	Yes	No
History of heart attack	Yes	No	Gynecologic
High blood pressure	Yes	No	Are you presently pregnant?	Yes	No
Varicose veins	Yes	No	Last menstrual date _______________________
Other _____________________________			Menopause - If yes, age ___________________
			Difficulty having intercourse	Yes	No
Respiratory
Asthma	Yes	No	Neurologic
Wheezing	Yes	No	Headache	Yes	No
Chronic cough	Yes	No	Tremors	Yes	No
Shortness of breath	Yes	No	Dizzy spells	Yes	No
Other _____________________________			History of fainting / seizures	Yes	No
			History of numbness / weakness	Yes	No
Hematologic/Lymphatic			Other __________________________________
Blood clotting problem	Yes	No
Easy bruising	Yes	No	Psychologic
Swollen glands	Yes	No	History of depression	Yes	No
Other _____________________________			Other __________________________________

Endocrine			Infections/Sexually Transmitted Diseases
Are you a diabetic?	Yes	No	Hepatitis	Yes	No
Excessive thirst	Yes	No	HIV /AIDS	Yes	No
Too hot / cold	Yes	No	Chlamydia	Yes	No
Tired / sluggish	Yes	No	Genital Herpes	Yes	No
Hypothyroid / Hyperthyroid	Yes	No	Genital Veneral Warts	Yes	No
Other _____________________________			Syphilis	Yes	No
			Other __________________________________

Physician use only:

Physician ______________________________________________ Date _______/_______/______________