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Urology Specialists
Urology Specialists
Patient: _____________________________ DOB: ___________ Chart #: ____________ Date: _______________

Patient Information (Please complete this page and the medication/allergies page )

1.) Medication Allergies: __________________________________________________________
  a. Are you allergic to latex? yes / no

2.) List of previous surgeries and major medical illnesses:
   _____________________________________ ________________________________________
   _____________________________________ ________________________________________
   _____________________________________ ________________________________________
   _____________________________________ ________________________________________

3.) Social History
a. Employment: ______________________________________
b. Marital Status: _____________________________________
c. Smoking History: ____________packs per day for ________ years; I quit smoking ______________years ago.
d.) Drinking history:  type of alcohol ________________________
drinks per day ________________________

4.) Family History (alive or deceased, age, major medical illnesses):
Mother: ____________________________________________________________
Father: ____________________________________________________________
Brothers: __________________________________________________________
Sisters: ___________________________________________________________

a. Has anyone in your family ever had prostate cancer (relationship, age, treatment)? __________________________________________________________________________________________


5.) Review of Systems (have you had major difficulty with any of these symptoms now?)
A.) General
1.) Fever Y    N
2.) Chills Y    N
B.) Eyes
1.) Blurred Vision Y    N
2.) Pain Y    N
C. Neurologic
1.) Numbness/Tingling Y    N
2.) Dizziness Y    N
D. Endocrine
1.) Extreme Thirst Y    N
2.) Hot Flashes Y    N
3.) Extreme Tiredness Y    N
E. Gastrointestinal
1.) Abdominal Pain Y    N
2.) Nausia/Vomiting Y    N
3.) Heartburn Y    N
F.) Cardiovascular
1.) Chest Pain Y    N
2.) High Blood Pressure Y    N
3.) Blood Clots Y    N
4.) Swelling of Legs Y    N
G.) Skin
1.) Rash Y    N
2.) Itching Y    N
3.) Boils Y    N
H.) Musculoskeletal
1.) Neck Pain Y    N
2.) Back Pain Y    N
3.) Joint Pain Y    N
I.) Ear/Nose/Throat
1.) Ear Pain Y    N
2.) Sore Throat Y    N
3.) Sinus Problems Y    N
J.) Urologic
1.) Inability to Urinate Y    N
2.) Painful Urination Y    N
3.) Urinary Frequency Y    N
K.) Respiratory
1.) Wheezing Y    N
2.) Shortness of Breath Y    N
3.) Cough Y    N
L.) Lyumpatic
1.) Swollen Glands Y    N

I have read and understood each of the above questions. All answers I have provided are complete and accurate to the best of my ability.

Patient Signature: _______________________________________________ Date: ____________________