Vasectomy Patient Form Page 2
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2Tea drinker (type, amount, frequency:___________________)
Kidney stones/disease
Cola drinker (type, amount, frequency: ___________________)
Prostate cancer
Recreational drugs (type, amount, frequency: ________________)
Stroke
Marital status: (circle) S M D W
Medications (list): ____________________________________________________________
Patient Signature
Date
Physician Use Only
•
Physical Examination: General Appearance ______________________________Mental Status ___________________________
Height ________ Weight _______ Temp _______ Pulse _____ Resp Rate ______ BP supine/sitting ____________________
Normal
Abnormal Comments
Normal
Abnormal Comments
Penis
Spermatic Cord
Prepuce
Vas Deferans
Urethral Meatus
Epididymes
Scrotum
Testes
Assessment: elective sterilization. Plan: schedule office vasectomy. Discussed potential complications with patient.
Video reviewed/information given/questions answered.
Physician Signature
Date
Letter Dictated _________________
Vasectomy
Date ____________________ (Performed in standard fashion using sterile technique)
Yes
No
Comments
Spousal consent
Informed consent
Sedation with ______mg Midazolam
Sedation with ______mg Diazepam
Pulse Oximetry
1% Lidocaine
1% Lidocaine with Epinephrine
Hemoclips
Pathology specimen
Written instructions given
Analgesic prescription given
Assessment: Bilateral Vasectomy performed in standard fashion and with no complications. Plan: Follow-up semen analysis
until negative (specify # ______ )
Physician Signature
Date
Letter Dictated _________________
Office Use Only
•
Post Vasectomy Specimen
Date
Result
Initials/MD
Date Pt. Informed
Informed by Initials
Rev 3/07
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Parent category: Medical