Eastern Urological Associates, P.A.
Patient History Form
Today’s Date
Date of Last
Physical Exam
Note: This is a confidential record and will be kept in your physician’s office.
Information contained herein will not be released to anyone
without your authorization.
Last Name
First Name
Social Security No.
Date of Birth
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Middle
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Chief Complaint—what is the main reason for your visit today?
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Primary Care Physician
Please describe your problem in detail.
History of Present Illness– Please answers the following questions.
Location of the Problem
Abdomen
Back
How long does the problem last?
Leg Genitals
Front
Back
30 minutes
1 hour
It is always there
Other
Other
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Is anything else occurring at the same time?
On a scale of 1-10, with 10 being the most
severe, circle the number that best describes the problem.
Yes
No
Nausea
If yes, please explain
Rash
Headaches
1 2 3 4 5 6 7 8 9 10
Other
When did you first notice the problem?
2 days ago
2 weeks ago
Is the problem constant or variable?
1 month ago
Other
Dull then sharp
Does anything help or make the problem worse?
Does the problem interfere with your normal functions? Y N
If yes, please explain
Moving around
Standing Up
Very sharp then leaves
Always there
Lying on my side
Other
Other
Past Medical and Social History–
Please list all serious illnesses in your immediate family. (Examples: diabetes, tuberculosis, breast cancer, heart disease, etc…)
If Tuberculosis, confirmation of cure date
Smoking? Y- # packs
Please list any personal past illnesses and /or surgeries
and when they occurred.
N
Alcohol: Y- frequency
Are you on any medications? If yes, please list all
medications:
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Do you have allergies? Y or N If yes, please lists all.
Physician’s Use Only (comments/Notes)
Revised 4/10/2014
# Answers
0
1—2
3
Level of Service
1 or 2
3
4—5
N
Last Name
Review of Systems
First Name
Do you now have or have you experienced any problems related to the following systems during the last six months?
Circle Y e s or No.
Constitutional Symptoms
Gastrointestinal
Ear/Nose/Throat/Mouth
Fever
Y
N
Abdominal pain
Y
N
Ear infection
Y
N
Chills
Y
N
Nausea/vomiting
Y
N
Sore throat
Y
N
Headache
Y
N
Indigestion/
Y
N
Sinus problems
Y
N
Other
heartburn
Other
Eyes
Other
Genitourinary
Urine retention
Y
N
Blurred vision
Y
N
Cardiovascular
Double vision
Y
N
Chest pain
Y
N
Painful urination
Y
N
Pain
Y
N
Varicose veins
Y
N
Urinary frequency
Y
N
High blood
pressure
Y
N
Wheezing
Y
N
Frequent cough
Y
N
Y
N
Other
Other
Allergic / Immunologic
Respiratory
Other
Hay fever
Y
N
Integumentary
Drug allergies
Y
N
Skin rash
Y
N
Boils
Y
N
Shortness of
breath
Persistent itch
Y
N
Other
Other
Neurological
Tremors
Y
N
Dizzy spells
Y
N
Numbness/tingling Y
N
Other
Hematological/Lymphatic
Musculoskeletal
Swollen glands
Y
N
Blood clotting
problems
Y
N
Joint pain
Y
N
Neck pain
Y
N
Back pain
Y
N
Endocrine
Excessive thirst
Too hot/cold
Y
Y
Other
N
Psychological
N
Other
Tired/sluggish
Y
N
Are you generally satisfied with your
life?
Y
N
Other
Do you feel severely depressed?
Y
N
Have you considered suicide?
Y
N
Other
OB/GYN
How
many pregnancies have you had? ______________
OB
How many children do you have? __________________
When was your last menstrual period? ______________
Provider
Revised 4/10/2014
#Answer
Level of Service
0-1
2-9
10 +
Date
1 or 2
3
4 or 5
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