Medical History Form
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1
2Your Name: _________________________________________ Age: ______________ Date of Birth ______/______/______
Referring Physician ___________________________________________ Family Physician ___________________________
Pharmacy __________________________ Phone: __________________ Address __________________________________
Your occupation _____________________________________________________________ Retired? Yes
No
This information is now required by the Federal Government
Primary Language ______________________ Race ____________________ Ethnicity _____________________
CHIEF COMPLAINT
What is the main reason for your visit today to the Urologist? ____________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
List of all your current prescribed and over the counter medications:
(Please include Aspirin, Vitamins, Supplements, Sinus/allergy medications, etc.)
Drug Name & Dose ____________________________________ Drug Name & Dose ____________________________________
Drug Name & Dose ____________________________________ Drug Name & Dose ____________________________________
Drug Name & Dose ____________________________________ Drug Name & Dose ____________________________________
Are you ALLERGIC to any medications? Yes
No
If yes, Please list the medications you are allergic to: _____________________________________________________________
________________________________________________________________________________________________________
LIST ALL SURGERIES/DATES
Surgery: _________________________ Date: _____________ Surgery: _________________________ Date: _______________
Surgery: _________________________ Date: _____________ Surgery: _________________________ Date: _______________
Surgery: _________________________ Date: _____________ Surgery: _________________________ Date: _______________
Surgery: _________________________ Date: _____________ Surgery: _________________________ Date: _______________
MEDICAL HISTORY (circle the appropriate response in each column)
Do You Have a History of:
Does your family have a history of:
Relationship to Patient
Diabetes
Yes
No
Diabetes
Yes
No
__________________
Heart Disease
Yes
No
Heart Disease
Yes
No
___________________
Cancer
Yes
No
Type __________ Prostate Cancer
Yes
No
___________________
High Blood Pressure
Yes
No
Bladder Cancer
Yes
No
___________________
Kidney Stones
Yes
No
Kidney Cancer
Yes
No
___________________
Stroke
Yes
No
Circulation Problems Yes
No
___________________
Bleeding Disorder
Yes
No
Type __________ Father Living?
Yes
No
Breathing Problem
Yes
No
Type__________
Mother Living?
Yes No
Other ________________________________________
Cause of Death (Father) _______________________
____________________________________________
Cause of Death (Mother) ______________________
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