Name: _____________________________________________ Date
Name: _____________________________________________ Date: _______________
Who referred you to Drs. Finder and Masel?
Why have you come for urological evaluation and how long have you had this problem?
Please check the boxes next to your medical problems:
□Blood in the urine □Heart disease/ heart attacks □Asthma
□Burning with urination □Strokes/TIAs □Seizures
□Incontinence/leaking of urine □High blood pressure (hypertension) □Emphysema
□Erectile dysfunction/Impotence □Diabetes □Stomach ulcers
□Urinary infections □Cancer; Type?_____________________ □Kidney stones
Others:_______________________________________________________________________________________
Please list any operations that you have had:
Surgery Year Surgery Year
1 4
2 5
3 6
What medications are you allergic to?______________________________________________________________
Please list all medications you now take:
1 4
2 5
3 6
Do you smoke? _______________ Do you drink alcohol? ______________
Do you live alone or with family? ________________________________________________________
If your parents are deceased, please list their age at death and cause of death: ______________________________ ____________________________________________________________________________________________
Additional Information:
................
................
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