Patient Medical History

Today's Date

Name

Date of Birth

Referring Doctor

Primary Care Doctor

Reason For Visit

Frequent urination

Incontinence

Pelvic pain, bladder pain

Interstitial cystitis

Urinary infection

Frequent urinary infections

Kdiney stones

Blood in urine

Prostate check

Elevated PSA

Prostatitis

Testicular pain

Testicular mass

Erection problems

Infertility

Blood in semen

other

If other

Medical History

I have no medical problems or illness

Please check off all medical problems and write down any that are not listed.

Arthritis

Asthma

Depression

Diabetes

Emphysema

Gastritis/ulcer

Glaucoma

Heart disease

High cholesterol

Hypertension

Irrerular rhythm

Liver disease

Parkinson's

Seizures

Stroke

Thyroid

Cancer

Other

Types of cancer

If other

Medications

I take no medications

yes (include dosage, aspirin and non-prescription items)

Medications

Allergies or Sensitivities

I have no allergies

Include medications, foods, dyes

Surgery

I have had no sergery

yes (include dates and side of body - i.e. left knee, right hernia)

Surgeries

Family History

Please list all serious illnesses in your immediate family (parents, grandparents, siblings, children but not your spouse)

Social History

Do you currently smoke tobacco?

Yes

packs per day

Do you drink alcohol?

Yes

glasses per week

Do you use recreational drugs?

Yes

which ones

Review of Systems: Are you currently experiencing any of the following symptoms?

General

Fever

Yes

Chills

Yes

Fatigue

Yes

Skin

Bruising

Yes

Itching

Yes

Rash

Yes

ENT

Headache

Yes

Ringing in ears

Yes

Nasal congestion

Yes

Respiratory

Shortness of breath

Yes

Coughing

Yes

Wheezing

Yes

Cardiovascular

Chest pain

Yes

Palpitations

Yes

Swelling of feet

Yes

Gastrointestinal

Abdominal pain

Yes

Constipation

Yes

Nausea

Yes

Vomiting

Yes

Male and Female Genitourinary

Blood in urine

Yes

Burning urination

Yes

Flank pain

Yes

Frequent urination night

Yes

Frequent urination day

Yes

Incontinence

Yes

Male Only

Erection problems

Yes

Penile lesions

Yes

Testicular mass

Yes

Testicular pain

Yes

Urethral Discharge

Yes

Musculoskeletal

Back pain

Yes

Joint pain

Yes

Muscle pain

Yes

Neurological

Dizziness

Yes

Seizures

Yes

Weakness

Yes

Endocrine

Appetite change

Yes

Excessive thirst

Yes

Hematology

Blood clots

Yes

Enlarged lymph nodes

Yes

Prolonged bleeding

Yes

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