HOUSTON METRO UROLOGY
Patient History Form
Name:
Date of Birth:
Date:
Referring Doctor:
Doctor you are seeing today:
Why are you seeing the doctor today?
How long have you had this problem?
ALLERGIES – Please list ALL types: or circle NONE
PAST MEDICAL HISTORY Please CHECK if you have or have had any of the following diseases or conditions:
Cardiovascular
Anemia
Angina (Chest Pain)
Aortic Aneurysm
Arrhythmia (Irregular Heartbeat)
Atrial Fibrillation
Bleeding Disorder
Cerebrovascular Disease/Stroke
Congestive Heart Failure
Coronary Artery Disease
Deep Vein Thrombosis (Blood clots)
Heart Attack
Heart Murmur
Heart Valve Problem/Replacement
Hypertension (High Blood Pressure)
Mitral Valve Prolapse
Sickle Cell Anemia
Thrombophlebitis
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Endocrine/Metabolic
Diabetes Mellitus, non-insulin dependent
Diabetes Mellitus, insulin dependent
Gout
Hyperthyroidism (High)
Hypothyroidism (Low)
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General
Allergies
Hernia
Location________
Hypercholesterolemia (High
cholesterol)
Malaise (Weak/Tired)
Sleep Apnea
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GI
Cholelithiasis (gallstones)
Colitis
Constipation
Crohn’s Disease
Diarrhea
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Diverticulosis
GERD (Acid Reflux, Indigestion)
Hemorrhoids
Hepatitis
Inflammatory Bowel Disease
Peptic Ulcer
Ulcerative Colitis
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GU
AIDS
Bladder Stone
Bladder Infection (UTI)
Chronic Renal Insufficiency
Erectile Dysfunction
Hematuria (blood in urine)
Interstitial Cystitis
Irradiation Therapy
Kidney Infection
Kidney Stones
Neurogenic Bladder
Orchitis (testicular infection)
Polycystic Kidney Disease
Recurrent UTI
Transplant Recipient
Uretheral Cancer
Undescended Testicle
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GYN/OB
Endometriosis
Menopause
Osteoporosis
Uterine Fibroids
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HEENT
Blindness
Cataracts
Glaucoma
Mumps
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Musculoskeletal
Arthritis
Back Pain
Fibromyalgia
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Neuro/Psych
Alcoholism
Alzheimer’s disease
Anxiety
Bi-polar Disorder
Chronic Fatigue Syndrome
Depression
Epilepsy
Migraine
Multiple Sclerosis
Parkinson’s
Spinal Cord Injury
Stroke
Suicide Attempt
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Respiratory
Asthma
Bronchitis
Emphysema (COPD)
Pneumonia
Pulmonary Embolism
Tuberculosis (TB)
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Tumors
Bladder Tumor
Brain Tumor
Breast Cancer
Cervical Cancer
Colon Cancer
Lung Cancer
Lymphoma
Melanoma
Ovarian Cancer
Prostate Cancer
Renal Cell Cancer (kidney)
Testicular Cancer
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PLEASE INITIAL HERE IF YOU HAVE NO DISEASES_________PLEASE LIST ANY OTHER DISEASES OR
CONDITIONS:___________________ _______________________________________________________________________________
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SURGICAL HISTORY
Please CHECK if you have any of the following surgeries & indicate the year of surgery:
CARDIOVASCULAR
Angioplasty
Aortic Aneurysm Repair
CABG
Carotid Artery Surgery
Heart Surgery (Stents)
YEAR
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YEAR
Heart Transplant
Lymphatic Node Dissection
Pacemaker Insertion
Artificial Heart Valves
GENERAL
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YEAR
Brain Surgery
Disc Surgery
Lumpectomy of Breast
Parathyroidectomy
Pilonidal Cyst Incision
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R L ______
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Skin Grafting
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Inguinal (groin) Hernia
GI
Interstim
Appendectomy
Kidney Stone
Bariatric Surgery (Obesity)
Laser Ureteral -
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Bowel Resection
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Cholecystectomy (Gall Bladder)
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Colon Resection
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Colonscopy
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EGD
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Fissurectomy
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Hemorrhoidectomy
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Illeostomy
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Inguinal Hernia
R L ______
Laparascopy
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Liver Disease
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Lysis Adhesions
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Spleenectomy
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Umbilical Hernia
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Ventral Hernia Repair
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GU
Bladder Surgery
Biopsy Prostate
Brachytherapy(Seed Implant)
Circumcision
Cystoscopy
Cystoscopy-Dilation
Cystoscopy-Retrograde
Cystoscopy-Stent
Epidiymectomy
ESWL (Shockwave Stones)
R
Hernia Repair
R
Hydrocelectomy
R
Ileal conduit
Indigo Laser Surgery
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Stone Tretment
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Salpingectomy (tubes)
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Tubal Ligation
Vaginectomy
Vulvectomy
R L ______
Meatotomy
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Needle Biopsy Prostate
HEENT
Cataract Surgery
R L ______
Eye Surgery
R L ______
Thyroid Surgery
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Penectomy
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Penile Surgery
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Pyeloplasty
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Radical Prostatectomy
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Renal Transplant
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Spermatocelectomy
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TUMT Prostate (Microwave)
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TUNA Prostate
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TURBT (Bladder Tumor)
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TURP prostate resection
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Ureteroscopy
R L ______
Variocelectomy
R L ______
Vasectomy
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MUSCULOSKELETAL
Amputation
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VLAP
SKIN
Nephrectomy –
(kidney removal)
Facial Surgery
R L ______
Septoplasty
Open Nephrolithotomy
(removal of stones)
Orchiectomy (testes removed)
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Sinus Surgery
Tonsil Surgery
R L ______
Orchlopexy
Penile Implant/Prosthesis
(Laser Ablation of Prostate)
GYN
C-Section
Hysterectomy Abd or Vag
Oophorectomy (ovaries)
Nasal Surgery
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Location: ____________________________
Arthroscopic Knee Surgery
Back Surgery
Carpal Tunnel Surgery
Foot Surgery
R
Hand Surgery
R
Hip Surgery
R
Knee Surgery
R
Leg Surgery
R
Shoulder Surgery
R
RESPIRATORY
Lung Surgery
Basal Cell Carcinoma
Melanoma
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Squamous Cell Car
Please initial here if no surgeries_____ Please indicate the dates of any other surgeries and describe:
2 PATIENT NAME:
R
Cervical Spine Surgery
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L ______
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L ______
L ______
L ______
L ______
L ______
L ______
R L ______
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FAMILY HISTORY
Please indicate which family member has/had any of the following: (Mother, Father, Siblings, Grandmother,
Grandfather, Aunt, Uncle)
Arthritis
Malignant Melanoma
Kidney Cancer
Diabetes
Bedwetting
Laryngeal (throat) Cancer
Kidney Disease
Gout
Bladder Cancer
Pancreatic Cancer
Kidney Stones
Heart Attack
Cancer (site unknown)
Prostate Cancer
Leukemia
Hypertension
Crohn’s Disease
Stroke
Liver Disease
Thyroid Disease
Depression
Tuberculosis
Other______________________________________________________________________________________________
SOCIAL HISTORY
Marital Status:
Single
Married
Number of Dependents (children):
Separated
Divorced
Widowed
# of each, if living with you:
Life Partner
Common Law Spouse
___Sons___Daughters___Stepchildren___Adopted___Foster_____Parents_____Grandparents
Alcohol Consumption:
None
Yes
Occasional/Social
# of drinks per day _______
Tobacco per day:
None
Yes
#_______Packs/day
______Cigarettes/day
_____Smokeless Tobacco
If you previously smoked, when did you quit? ___________ How many years smoked? _________ # of packs/day
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Caffeinated beverages:
None
Low(1-2)
Moderate (3-4)
Excessive (5 or more)
Women: Last Menstrual Period (date):______Are you pregnant? Yes
No
Number of Pregnancies? __________
Number of Vaginal deliveries? _______
Largest infant birth weight?____________
Occupation: (please circle one that applies): None
Laborer
Truck Driver
Executive
Professional
Part-Time
Retired
Other________________
Tradesman
Clerk
Administrative
Recent Foreign Travel (please circle all that apply)
None
Americas: Canada
Mexico
Latin America
South America
Other
World Wide: Europe
Africa
Middle East
Asia
Australia
Other
CURRENT MEDICATIONS –Initial here if you take no medications______
List ALL medications you are currently taking, including over the counter meds & supplements. (Attach list or
write on back of sheet if necessary
Aspirin
YES or NO
Drug Name
Dosage
Directions/How you take it
3 PATIENT NAME:
Drug Name
Pharmacy:
Pharmacy Address:
Pharmacy Number
4 PATIENT NAME:
Review of Systems
Please Mark with an X if you have recently experienced any of the
following:Constitutional
 Chills
 Thyroid disease
 Fever
Tired/Sluggish
 Fatigue
 Too Hot/Cold
 Generalized Weakness
Other ____________________________
 Hot Flashes
Gastrointestinal
 Night Sweats
 Abdominal pain
 Weight Loss
 Acid reflux
 Other ____________________________
 Bloody stools
Eyes
 Change in Bowel Habits
 Blindness
 Constipation
 Blurred vision
 Diarrhea
 Cataracts
 Hemorrhoids
 Glaucoma
 Indigestion/heartburn
 Glasses
 Irregular Bowl Movements
 Worsening Eyesight
 Nausea/vomiting
 Other __________________________
 Painful swallowing
Allergic/Immunologic
 Rectal bleeding
 Drug Allergies
 Tarry stools
 Other __________________________
 Other __________________________
Neurological
Cardiovascular
 Disoriented
 Chest pain/angina
 Dizzy spells
 Edema
 Headache
 Heart attack
 Leg or arm weakness
 Heart failure
 Memory loss
 Heart murmur
 Numbness/tingling
 High blood pressure
 Stroke
 Irregular heartbeat
 Speech Problems
 Mitral Valve Prolapse
 Tremors
 Shortness of breath
 Other ____________________________
 Skipped Heart Beats
Endocrine
 Swelling
 Diabetes
 Other _______________________________
 Excessive thirst
Skin
 Pituitary disease
 Acne
5 PATIENT NAME:
 Boils
 Urgency
 Changing Moles
 Urinary Frequency
 Persistent Itch
 Urinary Hesitancy
 Pigment Change
 Urine Incontinence (leakage)
 Skin Rash
 Urinary Tract Infections
 Other ______________________________
 Urine retention
Musculoskeletal
 Urologic Cancer
 Arthritis
 Urologic Surgery
 Back pains
 Vaginal Bleeding
 Gout
 Vaginal Discharge/Problems
 Joint pains
 Weak Stream
 Muscle Weakness
 Other
 Neck Pain/Stiffness
___________________________
 Other _______________________________
Respiratory
Ears/Nose/Throat
 Asthma
 Dry Mouth
 Emphysema-Bronchitis
 Ear Infection
 Frequent cough
 Hearing Problems
 Shortness of breath
 Sinus Problems
 Wheezing
 Sore Throat
 Other
 Other _____________________________
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Genitourinary
Hematologic/Lymphatic
 Back pain
 Bleeding problems
 Bedwetting
 Blood clotting problem
 Blood in urine
 Hepatitis
 Burning on urination
 HIV (AIDS)
 Dribbling
 Sickle Cell
 Erection/Ejaculation problems
 Swollen glands
 Flank pain (back pain)
 Other _______________________________
 Hematuria (Blood in urine)
Psychological
 Hesitancy
 Anxious
 Kidney Failure
 Depressed
 Kidney Infections
 Other _______________________________
 Kidney Stones
 Nocturia (getting up at night)
 Not Emptying
 Painful Ejaculation
 Sexually Transmitted Disease
 Stranguria
 Suprapubic Pain
6 PATIENT NAME: