Today’s Date__________ Springfield Urology Patient ...
Today’s Date__________ Springfield Urology Patient Information (Review of Symptoms)
Name________________________________________________________________________Age_________ DOB____________________
Chief Complaint: Please list the reasons for seeing the doctor, be as specific as you can____________________________________________
______________________________________________________________________________________
Medications: List all medications you are taking and the dosages______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Allergies: Do you have any allergies? YES□ NO□
Please list any allergies to medications, foods, X-Ray Dye____________________________________________________________________
Surgery: Please list any surgical/ anesthetic procedures and approximate date
_________________________________ ______________________________
_________________________________ ______________________________
_________________________________ ______________________________
Family History: Does anyone in your family (parents, siblings, and children) have the following? If yes, list family member
Diabetes: YES□ NO□ __________________________________________________________________________
Heart Disease: YES□ NO□ ______________________________________________________________________
Kidney Disease/ Stones: YES□ NO□ ______________________________________________________________
Kidney Stones: YES□ NO□ ______________________________________________________________v
Prostate Cancer: YES□ NO□ ____________________________________________________________________
Cancer: YES□ NO□ ___________________________________________________________________________
Social History:
Occupation/ Former occupation:_______________________________
Current Smoker? YES□ NO□ Prior Smoker? YES□ NO□
Packs per day?______ How many yrs?______ Year Quit?_____
Do you use alcohol?___________________ How much?__________ Other drugs?________
Gynecologic: # of pregnancies______ # of children?_____ Last Menstrual Period?_____
Do you now or have you had any problems related to the following systems? Circle Yes or No
Please explain any Yes answers in the space provided.
|Constitutional | | | |Endocrine | | |
|Fatigue |Y |N | |Diabetes |Y |N |
|Fever |Y |N | |Excessive Eating (Polyphagia) |Y |N |
|Eye, Ear, Nose, Throat | | | |Excessive Thirst (Polydipsia) |Y |N |
|Headache (Migraine Only)** |Y |N | |Goiter |Y |N |
|Hearing Loss |Y |N | |Jaundice |Y |N |
|Vision Loss |Y |N | |Muscular/ Skeletal | | |
|Respiratory | | | |Arthritis |Y |N |
|COPD |Y |N | |Back Pain |Y |N |
|Cough |Y |N | |Gout |Y |N |
|Difficulty Breathing |Y |N | |Genitourinary | | |
|Immunologic | | | |BPH |Y |N |
|Asthma |Y |N | |Kidney Stone |Y |N |
|Cardiovascular | | | |Renal Disease |Y |N |
|Chest Pain (Angina)** |Y |N | |Urinary Tract Infection |Y |N |
|Congestive heart failure |Y |N | |Allergic / Immune | | |
|High Blood Pressure |Y |N | |Food Allergies |Y |N |
|Irregular Heartbeat/ Palpitations |Y |N | |Shell Fish Allergy |Y |N |
|Myocardial Infarction (heart attack) |Y |N | |Psychiatric | | |
|Gastrointestinal | | | |Anxiety |Y |N |
|Abdominal Pain |Y |N | |Depression** |Y |N |
|Constipation |Y |N | |Psychiatric Symptoms |Y |N |
|Diarrhea |Y |N | |Neurological | | |
|Fecal Incontinence |Y |N | |Gait Disturbance |Y |N |
|GERD |Y |N | |Seizures ** |Y |N |
|Inflammatory Bowel Disease |Y |N | |Stroke |Y |N |
|Vomiting |Y |N | |Blood/ Oncology | | |
|Peripheral Vascular | | | |Bleeding Disorder |Y |N |
|Varicose veins |Y |N | |Bleeds Easy |Y |N |
|Dermatology | | | |Bruises Easy |Y |N |
|Rash |Y |N | |Cancer |Y |N |
Dr. ________________________________Reviewed the following information on___________________.
Signature Date
................
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