Southwest Urologic Specialists, PC
PATIENT HISTORY FORM
CONFIDENTIAL: This is a confidential record and will be kept in your doctor’s office.
Information contained here will not be released to anyone without your consent.
Date __________________
Last Name ________________________________
Nickname __________________________
First Name ______________________MI____
DOB_____________________
Gender _________
Reason for Visit _____________________________________________________________________
Medical History
Allergies NO if yes, ________________________
________________________ ________________________ ________________________ ________________________
________________________ ________________________ ________________________ ________________________
________________________ ________________________ ________________________ ________________________
Medical Conditions (for example- Colon Cancer, Hypertension, Diabetes, etc.)
_____________________________________ Year_______
__________________________________
_____________________________________ Year_______
__________________________________
_____________________________________ Year_______
__________________________________
_____________________________________ Year_______
__________________________________
_____________________________________ Year_______
__________________________________
Year_______
Year_______
Year_______
Year_______
Year_______
Infections
Have you ever had? : Rheumatic Fever, Tuberculosis, HIV,Valley Fever, MRSA, Vancomycin Resistant Enterococcus
Surgeries
_____________________________________ Year_______
__________________________________ Year_______
_____________________________________ Year_______
__________________________________ Year_______
_____________________________________ Year_______
__________________________________ Year_______
_____________________________________ Year_______
__________________________________ Year_______
Name of Drug
Dose (mg)
# Tablets
# times per day
_____________________________________________
_________ _________ ___________
_____________________________________________
_________ _________ ___________
_____________________________________________
_________ _________ ___________
_____________________________________________
_________ _________ ___________
_____________________________________________
_________ _________ ___________
_____________________________________________
_________ _________ ___________
Over the Counter Medication (Aspirin, Tylenol, vitamins, fish oil, etc.)
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
Social History
Married? □ Yes □ No
Single? □ Yes □ No
Divorced? □ Yes □ No
Widowed? □ Yes □ No
Tobacco Use □ Yes □ No cigarette/cigar/pipe/chew
How much? _____ day
When? ______ until ____________
Have you ever used recreational drugs (marijuana, cocaine, etc.)? __________ When? ____________________________
Alcohol Use □ Yes □ No If yes, # drinks per week ________
Employment:
□ Employed
□ Retired
□ Unemployed
Present Occupation _________________________________
Present Employer _______________________________
Past Occupation ____________________________________
Past Employer _________________________________
Family History
Relative
Father
Mother
Sister(s)
Brother(s)
Children
Living?
Deceased?
#
#
#
#
#
#
Major Illnesses
Is there any history in your family of
□ Heart Disease
Relation ___________________
□ Kidney Disease
Relation ___________________
□ Kidney Stones
Relation ___________________
□ Prostate Cancer
Relation ___________________
Cause of Death
□
□
□
□
Diabetes
GI problems
Bleeding Disorder
Other
Relation
Relation
Relation
Relation
Age
___________________
___________________
___________________
___________________
Review of Systems
Do you now or have you had any problems related to the following systems? “Y” or “N” must be circled or “N” will be assumed.
Constitutional
Weight Loss
Weight Gain
Chills
Fever
Itching
Night Sweats
Other
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
Eyes
Glaucoma
Cataracts
Glasses/Contacts
Blurred Vision
Eye Pain
Other
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
Neurological
Tremors
Dizziness
Numbness/Tingling
Stroke
Seizures
Insomnia
Other
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
Endocrine
Excessive Thirst
Too Hot / Cold
Other
Cardiovascular
Chest Pain
Tightness in Chest
Irregular Heartbeat
Ankle Swelling
High Blood Pressure
Shortness of Breath
Heart Enlarged
_________________
Musculoskeletal
Muscle Weakness
Joint Pain/Swelling
Sciatica
Muscle Pain
Muscle Cramps
Stiffness
Other
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
_________________
_________________
Gastrointestinal
Abdominal Pain
Nausea/Vomiting
Indigestion/Heartburn
Constipation
Diarrhea
Other
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
_________________
Psychological
Depression
Anxiety
Seeing a Psychiatrist
Psychiatric Diagnosis
Other
Y
Y
Y
Y
Y
N
N
N
N
N
_________________
_________________
Y
Y
Y
Y
Y
N
N
N
N
N
_________________
Y
Y
Y
Y
N
N
N
N
Y
Y
Y
N
N
N
lbs ______
lbs ______
_________________
Y
Y
Y
N
N
N
Y
Y
Y
Y
N
N
N
N
Respiratory
Wheezing
Frequent Cough
Shortness of Breath
On Oxygen
Other
Ear/Nose/Throat
Pain in Ears
Discharge from Ears
Motion Sickness
Difficulty Hearing
Y
Y
Y
N
N
N
Trouble with Teeth
Trouble with Gums
Nose Bleeds
_________________
Low Blood Pressure
Heart Palpitations
Fast Heart Rate
Skipped Heart Beat
Heart Murmur
Y
Y
Y
Y
Y
Genitourinary
Change in Stream
Urinating at Night
Frequency (>8 times/day)
Burning with Urination
Blood in Urine
Trouble Starting Flow
Dribbling after Urination
Urinary Leakage
Other
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Hematologic/Lymphatic
Swollen Glands
Blood Clotting Problem
Bruising
Other
Y
Y
Y
Y
N
N
N
N
Sexual History
Change in Sex Drive
Sexual Performance Satisfactory
Y
Y
N
N
Men Only
Pain in Testicles
Swelling of Testicles
Blood in Semen
Discharge from Penis
Y
Y
Y
Y
N
N
N
N
_________________
_________________
Men Only:
Circle the Number
Not at all
Almost
Never
Less than
half the
time
About
half the
time
More
than half
the time
Almost
always
Over the past month, how often have you had a sensation of not
completely emptying your bladder after urinating?
0
1
2
3
4
5
Over the past month, how often have you had to urinate less
than two hours after you finished urinating?
0
1
2
3
4
5
Over the past month, how often have you stopped and started
again several times when urinating?
0
1
2
3
4
5
Over the past month, how often have you found it difficult to
postpone urinating?
0
1
2
3
4
5
Over the past month, how often have you had a weak urinary
stream?
0
1
2
3
4
5
Over the past month, how often have you had to push or strain to
begin urination?
0
1
2
3
4
5
On a nightly basis, how many times do you typically wake up to
urinate?
0
1
2
3
4
5
Total __________
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
Delighted
1
Pleased
2
Mostly Satisfied
3
Mixed
4
Mostly Dissatisfied
5
Unhappy
6
Terrible
I hereby acknowledge the above information is accurate and true.
Patient Signature _____________________________________________________Date_________________
Physician Signature __________________________________________________________________Date________________
Revised 6/12