Urology Patient Questionnaire Form
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1
2Commonwealth Urology Patient Questionnaire
Patient Name:_________________________________ DOB:___________________ Today s Date:______________
Referring Physician:_______________________________ Family Physician:________________________________
Home Phone: ____________________________________ Cell Phone: ____________________________________
HISTORY OF PRESENT ILLNESS:
1.
What is the problem that brings you here today?__________________________________________
2.
For what length of time have you had this problem?_________________________________________
3.
What signs or symptoms are you having?________________________________________________
4.
Does anything make the problem better or worse?__________________________________________
5.
Does the problem interfere with normal daily function? CIRCLE: YES
NO
6.
How long does the problem last? CIRCLE: seconds; minutes; hours; days; all the time
MEDICATIONS:
List the names (and dose if known) of the medication you take everyday (including non-prescription meds):
ALLERGIES (Please List):
Are you taking the following medications: CIRCLE: Coumadin
Glucophage
Plavix
Aspirin
PAST PERSONAL & FAMILY HISTORY
Please write Y (yes) or N (no) under SELF if you had any of the listed conditions.
Please write Y (yes) or N (no) under FAM if a family has had any of the listed conditions.
Condition
SELF
FAM
Condition
SELF
FAM
Condition
SELF
FAM
Anemia
Heart Attack
Radiation Therapy
Arthritis
Heart Problems
Seizures
Asthma
HIV/AIDS
Shortness of Breath
Bleeding Troubles
High Blood Pressure
Stomach Ulcers
Cancer
Hoarseness
Stroke
Cholesterol
Immune Disease
Thyroid Problems
Diabetes
Kidney Disease
Trouble w/ Anesthesia
Emphysema
Liver Disease
Tuberculosis
Glaucoma
Lung Disease
MEN: CIRCLE:
Abnormal PSA
Prostate Biopsy
Sexual Dysfunction
Have any of the men in your family ever had prostate cancer? YES__________ NO_____________
Is YES, Circle: Father
Brother
Grandfather
Uncle
Cousin
WOMEN: CIRCLE:
Abnormal Periods
Female Hormone Problem
Uterus/Ovaries-problem
Could you be pregnant now? YES_____ NO______ Are you on birth control now? YES_______ NO______
Type of birth control: Pill_____ Other______ Number of Pregnancies?_______ Number of Births_________
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Parent category: Life