Constitutional Symptoms
Fever Y N _____________
Chills Y N _____________
Headache Y N _____________
Others ______________________________
Allergic/immunologic
Drug allergies Y N _____________
Hay fever Y N _____________
Others ______________________________
Cardiovascular
Chest pain Y N _____________
High blood pressure Y N _____________
Swelling in legs Y N _____________
Others ______________________________
Respiratory
Wheezing Y N _____________
Shortness of breath Y N _____________
Frequent cough Y N _____________
Others ______________________________
Gastrointestinal
Abdominal pain Y N _____________
Nausea/Vomiting Y N _____________
Heartburn Y N _____________
Hematological/Lymphatic
Swollen glands Y N _____________
Clotting problems Y N _____________
Others ______________________________
Endocrine
Tired/Sluggish Y N _____________
Too hot/cold Y N _____________
Excessive Thirst Y N _____________
Others ______________________________
Integumentary
Skin rash Y N _____________
Persistent itch Y N _____________
Boils Y N _____________
Others ______________________________
Musculoskeletal
Joint Pain Y N _____________
Neck Pain Y N _____________
Back Pain Y N _____________
Others ______________________________
GENITOURINARY
Seen
by a Urologist before Y/N
(Name)____________________
Urine
infections (bladder/kidney)
Painful
urination
Discharge
from urine canal
Blood
in urine that you can see
Told you have blood on a
urine test
History
of Kidney stones
Stones
in urine
Leak
urine
Leak
urine with cough/strain/laughing
Strong
urge to urinate
Strong
urge to urinate causing leaking Bladder pressure
Frequent
urination
If
yes, how often daytime____________
Strain
or push to urinate
Wait
a long time to urinate
Slow
urine stream
Interrupted
urine stream
Dribbling
of urine
Urine
retention
Bladder
fullness after urinating
Wake
up at night to urinate
If
yes, how many times________
Other_______________________________________________________________
____________________________________________________________________
WOMEN ONLY
Date
of last menstrual period_____/_____/_____
Abnormal
menstrual period
If
yes, explain____________________________
It
is possible that I am pregnant
Presently
in menopause
SEXUAL HISTORY
Painful
intercourse
Loss
of interest
poor quality erections
no erections
no morning erections
Interested
in treatment/evaluation of sexual problem?
Other______________________
GENITAL INFECTIONS
Genital
bacterial infection
Genital
yeast infection
Sexually
Transmitted Disease (STD)
Other______________________
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# Answer Service
0-1 1
or 2
2 – 9
3
10+ 4
or 5
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