Vasectomy Encounter Form Page 2
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1
2Past Medical History
Epididymitis?
Y
N
Do you have bleeding tendencies?
Y
N
Mumps in the testicles?
Y
N
Do you take aspirin?
Y
N
Hernia/surgery?
Y
N
Do you take any regular medications?
Y
N
Trauma in the groin
Y
N
Have any major illness?
Y
N
VD, prostatitis, urine infection?
Y
N
Psychological counseling?
Y
N
Allergies to medications:
Have you read & understood handouts explaining vasectomy? Y
N
Videotape? Y
N
Online? Y
N
Access Code ______ date ______
PHYSICIAN TO FILL OUT:
Physical Exam:
Hernia?
Yes
No
Testicles
Normal
Abnormal
Vas - palpable bilaterally
Yes
No
Urethral discharge
Yes
No
Scrotal contents
varicocele
R
L
spermatocele R
L
Skin
Counseling:
Any questions regarding video or handouts?
Yes
No
Diagram given to patient ?
Yes
No
Impressio n:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Pla n:
Valium 1 0 mg
ib up r o fen 8 0 0 mg
Atropine 0.5 sub q
Dt
Vas scheduled
Yes
No
Other:
Physician Signature
Date
cc: ___________________________
POST OP
Date surgery performed _____________________
Complications_________________________________________________
RESULT
DATE
INITIALS
PT. NOTIFIED
Semen check #1____________________________
____________
____________
_____________
Semen check #2 ____________________________
____________
____________
_____________
Okay to give results to ________________________________ .
Okay to leave on answering machine? Y
N
PROBLEMS (see dictated note)
DATE
I.
II.
Vas Encounter Form/med/2012
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