Vasectomy Patient Form
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1
2Urology
Urology of Indiana, LLC
Date_________________
Indiana
of
Vasectomy Patient
Patient Name ___________________________________________________ Referring Physician ____________________________
Date of Birth ________________ Age _______ Weight __________ Height ___________ Race ________________ Sex __________
Chief Complaint: Desire Sterilization
Review of Systems: (check either yes or no for each item)
Yes No
Yes No
Yes No
Yes No
Fever/chills
Change in bowel habits
Blood in urine
Trouble swallowing
Swollen glands
Hoarseness
Loose/hard stools
Painful urination
General fatigue
Neck stiffness
Bloody stools
Frequent urination
Rash
Shortness of breath
Black tar stools
Urgent urination
Changing moles
Frequent coughs
Dizziness
Nighttime urination
Bruise easily
Cough up blood
Leg/arm weakness
Weak urinary stream
Headaches
Night Sweats
Slurred speech
Leakage of urine
Blurred vision
Irregular heartbeat
Memory loss
Penile discharge
Light flashes
Joint pain/swelling
Chest pain
Genital warts
Earache
Swelling of legs/arms
Back pain
Testicular mass
Deafness
Poor appetite
Constant thirst
Loss of sex drive
Nose bleeds
Always cold/hot
Early ejaculation
Heartburn
Sinus problems
Nausea/vomiting
Often depressed
Loss of erections
>
Allergies: Circle if you are allergic to penicillin, sulfa drugs, aspirin, mycins, codeine, morphine, or IVP dye?
Please list all other drug allergies and nature of reaction_________________________________________________
>
Anesthesia: Have you ever had a reaction to an anesthetic? ___No ___Yes, if yes, please specify anesthetic type
and reaction _____________________________________________________________________________________
Past and Present Medical History: [check all items either No or Yes (Now) or Yes (Past)]
No Yes (Now) Yes (Past)
No Yes (Now) Yes (Past)
Alcoholism
Mental Disorder
Cancer
Gastrointestinal disease
Epilepsy/seizures
Heart murmur
Glaucoma
Heart attack
Hepatitis
Blood clots
Kidney stones
Heart disease
Kidney disease
Heart fluttering
Bladder problems
Vascular disease
Venereal disease
High blood pressure
Urinary tract infection
Low blood pressure
Enlarged testis(es)
Rheumatic fever
Thyroid disease
Neurological disorder
Muscle disease
Respiratory disease
Tuberculosis
Stroke
Anemia
AIDS/HIV +
Hemophilia
Other (specify)
Diabetes
Family History:
Social History: (check Yes or No for each item
Yes No
(check all that apply/indicate family member)
Currently smoke cigarettes (packs/day ____ # of years____)
Anesthesia problems
Former cigarette smoker (year quit __________)
Cancer
Diabetes
Alcohol drinker (type, amount, frequency:___________________)
Heart Disease
Coffee drinker (type, amount, frequency: ___________________)
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