ASSOCIATES IN UROLOGY

PATIENT QUESTIONNAIRE

NAME_______________________________________________    SEX__________    DATE_____________

(FIRST) (LAST)

ALLERGIES TO MEDICATIONS:________________________________

CURRENT MEDICATIONS (with doses and frequency)  _________________________________________________

__________________________________________________________________________________________

SOCIAL HISTORY:

Occupation:                                        

Marital Status:

Tobacco: Never______    Presently (Packs/Day)______   Quit (Year and Packs/Day)_____________________

Recreational Drugs: Never______    Presently (Type)_________________    Quit (Type)__________________

Alcohol: Never______    Socially______    Daily (Drinks/Day)______

FAMILY HISTORY:

Mother: Alive______    Deceased (Age)______    Cause of Death_____________________

Father: Alive______    Deceased (Age)______    Cause of Death_____________________

Immediate family members with history of:

            Kidney Stones______    Prostate Cancer______    Kidney Disease______    Kidney Cancer______

            Bladder Cancer______    Diabetes______    Heart Disease______    Gynecologic Cancer______

PAST MEDICAL HISTORY: (Please Circle All That Apply)

Urology:   bladder cancer,  BPH,  erectile dysfunction,  interstitial cystitis,  kidney cancer,  kidney infection, 

kidney stones, prostate cancer,  prostatitis,  testicular cancer,  urethral stricture,  kidney stone disease,  other -   

Eyes:   glaucoma,  blindness,  other -  

ENT:  deafness,  allergies,  throat cancer,  other -

Cardiovascular:  arrhythmia,  congestive heart failure,  elevated cholesterol,  hypertension,  heart attack, 

 coronary artery disease,  valve disease,  peripheral vascular disease, other -

anticoagulant use:  aspirin,  plavix,  coumadin,  vitamin E

PAST MEDICAL HISTORY (Cont)

Respiratory:  emphysema,  pneumonia,  asthma,  COPD,  bronchitis,  lung cancer,  other -

Gastrointestinal:   hiatal hernia,  pancreatitis,  peptic ulcer disease,  reflux disease,  inflammatory bowel disease

(Crohn's disease / ulcerative colitis),  diverticulitis,  colon cancer

Renal:  renal insufficiency,  renal failure,  polycystic kidney disease,  other - 

Gynecologic:  endometriosis,  deliveries (vag#)_____  (c-section#)____,  menopause,  ovarian cancer, 

uterine cancer,  cervical cancer,  other -

Breast:  breast cancer,  other -

Orthopaedic:  herniated disk,  arthritis,  osteoporosis,  other -

Neurologic:  migraine headaches,  multiple sclerosis,  epilepsy,  brain tumor,  other -  

Endocrine:  hyperparathyroidism,  diabetes mellitus,  hyperthyroidism,  hypothyroidism,  gout,  other - 

Skin:  melanoma,  non-melanoma skin cancer,  other -

Hematology:  anemia,  deep venous thrombosis,  sickle cell disease/trait,  lymphoma,  leukemia,  other -

Psychiatric:   anxiety,  depression,  schizophrenia,  other -    

PAST SURGICAL HISTORY: (Please Circle All That Apply):

Urology:  circumcision,  ESWL,  laser stone treatment (kidney, ureter, bladder), percutaneous nephrolithotomy, 

R/L orchiectomy,  laser treatment of prostate,  radical retropubic prostatectomy,  robotic prostatectomy,  testicular torsion, 

resection of bladder tumor,  urethroplasty,  R/L varicocelectomy,  TURP,  R/L nephrectomy (open / laparoscopic),  other -

Eyes:  cataracts,  other -   

ENT:  tonsils and adenoidectomy,  sinus surgery,  other - 

Respiratory:   lung resection for cancer,  other - 

Heart surgery:  heart bypass,  pacemaker placement,  valve replacement,  other -

General surgical:  gastric bypass surgery,  peptic ulcer repair,  cholecystectomy,  appendectomy,  colon resection, 

hernia repair (side and type__________________________________),  other -

Gynecologic:  hysterectomy,  c-section,  bladder suspension,  sling,  other -

Breast:  mastectomy,  lumpectomy,  other -

Orthopaedic:  arthroscopy,  laminectomy,   foot surgery,  hip surgery,  knee surgery,  other - 

Neurologic:  brain surgery,  other -

Endocrine:  parathyroidectomy,  thyroidectomy,  other -

REVIEW OF SYSTEMS: (Please Circle All That Apply)

Urinary:  none,  «urgency,» «urine retention,» «painful urination,» «urinary frequency,»  blood in the urine,

incontinence of urine,  «other -»

Constitutional:  «none,» «headache,» «fever,» «chills,» «other -»

Eyes: «none,» «blurred vision,» «double vision,» «eye pain,» «other - »

Ears/Nose/Throat/Mouth: «none,» «ear infections,» «sore throat,» «sores,» «sinus problems,» «other - »

Cardiovascular: «none,» «chest pain,» «heart murmur,» «high blood pressure,» «varicose veins,» «other - »

Respiratory: «none,» «wheezes,» «frequent cough,» «shortness of breath,» «other - »

Gastrointestinal: «none,» «abdominal pain,» «nausea,» «vomiting»,  «indigestion/heartburn,» «other - »

Neurological: «none,» «tremors,» «dizzy spells,» «numbness,» «tingling,» «other - »

Hematologic / Lymphatic: «none,» «swollen glands,» «blood clotting problems,» «other - »

Allergic / Immunologic: «none,» «hay fever,» «drug allergies,» «other -»

Endocrine: «none,» «excessive thirst,» «too hot,» «too cold,» «tired,» «sluggish,» «other - »

Musculoskeletal: «none,» «joint pain,» «back pain,» «neck pain,» «other - »

Psychological: «none,» «depressed,» «suicidal,» «other - »

Gynecological (Women only): «none,» «menopause,» «pregnant, » «possibly pregnant,» «other - »

Skin: «none,» «rash,» «hives,» «persistant itch,» «boils,»  other -