GENERAL UROLOGY QUESTIONNAIRE
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- George Lambert
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1 Bruce R. Gilbert, M.D., Ph.D. Director, Reproductive and Sexual Medicine Smith Institute For Urology North Shore - Long Island Jewish Health System Date: GENERAL UROLOGY QUESTIONNAIRE Please fill out the following form as honestly and completely as you can. The purpose of this information is to help assess your reproductive potential. Your thoroughness in its completion is essential to evaluation and treatment. All information will be held in strict confidence. Please bring this form with you on your first visit. PRIMARY REASON FOR YOUR VISIT: A. Identification: Name: Address: Birthdate: Birthplace: Ethnic Origin: Age: Gender: Male Female Telephone (home): Telephone (work): Referred by: Who is your primary Medical Doctor: Please list in order of importance (the most important first) all concerns you have regarding your health and well-being: Marital Status: single divorced married separated widowed Partners name: Age: Gender: Male Female B. Fertility History: 1. Have you achieved pregnancy with your current partner in the past? If yes, please give dates and note any adverse outcome_ 2. Have you had a pregnancy with a previous partner? If yes, please give dates and note any adverse outcome_ 3. Have you ever undergone sterilization (e.g.,vasectomy)? 4. Have you received treatment for infertility problems elsewhere?_ C. Sexual History: 1. Rate your level of sexual desire: marked moderate slight none 2. How many times each week do you have sexual activity (e.g., intercouse, masterbation)? 3. Rate you partners level of sexual desire: marked moderate slight none YES NO Please list treatments Men: 7. Do you obtain an erection easily? 8. Do you often have erections in the morning? 9. Are you aware of erections in the night? 10. Have you ever ejaculated through a flaccid (soft) penis? 11. Do you often ejaculate prior to penetration for intercourse? Women: 12. Do you have pain with intercourse? 13. Do you feel that you have adequate lubrication with sexual excitement? 14. Have you noticed a change in your sexual response? 1.
2 15. Are you subject to vaginal infections? 16. Are your menstrual periods regular (LMP)? 17. Are you post (or peri) menopausal (LMP? 18. Have you had a hysterectomy? 19. Do you take hormone replacement? Both Men and Women: 16. Do you use any form of lubrication for intercourse? if so, what type 17. Rate you partners level of sexual desire: marked ;moderate ;slight ;none 18. Have you or your partner ever had any of the following illnesses? If so, please note date and treatment: Herpes simplex (Type I or II): Pelvic inflammatory disease (PID): Venereal disease (VD): Gonorrhea (GC): Non-specific urethritis (NSU): Syphilis: 19. Do you or have you had kidney disease (stone, infection, tumor etc) Please describe: 20. Do you or have you had Bladder disease (stone, infection, tumor, incontinence) Please describe: 21. Does urine leak out when you cough, sneeze, laugh or with physical excersie? If so, do you wear pads? _ How many/day? 22. Do you wet the bed at night? 23. Do you have pain with urination? 24. Do you have blood in your urine? 25. Do you have recurrent urinary infections? D. General Medical History: 1. Have you ever had any of the following illnesses or conditions: Allergies (Medicines, Enviornmental, Foods: please list) Arthritis Bowel disorders Cancer Change in body appearance Change in facial appearance Color blindness Deafness Diabetes Heart problems Hepatitis HIV infection (AIDS) Liver Disease Lung or breathing problems Thyroid disease Generalized viral infection (i.e.,mono,encephalitis) Nervous system or Psychiatric disease Sickle cell disease Smallpox Influenza Tuberculosis Ulcers Frequent episodes of indigestion or abdominal pain Neck or back problems Skin diseases High blood pressure Seasonal illnesses (e.g.,respiratory, skin, GI) 2. YES NO Please describe
3 E. Urological History: 1. Have you ever had infection of the: prostate NA YES NO Please List Treatments epididymis testicles bladder kidney 2. Have you ever had kidney stones? 3. Have you had: venereal disease (VD) non-specific urethritis (NSU) Gonorrhea (GC) Syphillis Herpes simplex (Type I or II) 4. Have you ever had a clear, white, yellow or green discharge from the tip of your urethra? 5. Have you ever had a urinary tract infection (UTI)? 6. Have you had a fever in the past three months? 7. Have you ever had blood in your semen (ejaculate)? 8. Have you ever had pain in your scrotum or testicles? 9. Were either of your testicles undescended at birth? 10. Have you ever had any injury to your testicles or penis? 11. Have you ever had mumps? if yes, did it affect your testicles: 12. Have you ever had an operation for (please give dates): Hernia Varicocele (varicose veins in the scrotum) Hydrocele Undescended testis Any abdominal surgery Operation on the testis Vasectomy Circumcision or other surgery on the penis Operation on on Uterus or vagina Operation on Ovary of fallopian tube Other surgery (please list with dates) Have you ever had a blood transfusion (Date) F. Endocrine History: 1. Do you have or have you ever had: YES NO Difficulty smelling Headaches (persistent or recurrent) Visual problems Enlarging hands or feet Problems with perspiration/sweating Changing skin color Frequent episodes of lightheadedness or dizziness Growth problems Do you have a general sense of well being Do you notice a recent change in your energy level Do you have wide mood swings 2. At what age did you first: note armpit hair _ pubic hair _ shave _ 3.
4 3. How often do you shave: once a day twice a day once a week twice a week or less 4. Is their any change in the texture or quantity of body hair? 5. How does your beard compare with other men in your family: same sparser heavier G. Occupational/Educational History: 1. What is your highest level of education (circle one): High School, College, Graduate School 2. Please list any College Degrees (with Major): 3. What is your present occupation? 4. Past occupations? YES NO INDICATION 5. Is your occupation stressful? 6. Do you need to meet rigid deadlines or time schedules? 7. Do you frequently travel? 8. Do you fall asleep easily? 9. Do you wake up early? 10. In your work have you been exposed to any of the following: Prolonged heat Radiation Pesticides Agent orange Industrial solvents Dyes Heavy metals Plastics H. Medications and Drugs: 1. Are you taking or have you taken any of the following medications: Allopurinol Antidepressant drugs Antihistamines Antihypertensive drugs Antiparasite agents Anti psychotic agents Aspirin Barbituates Chemotherapy for cancer Cholestyramine Clofibrate Digitalis Dilantin Diuretics Hormones (estrogen,testosterone,thyroid,cortisone) Immunosuppresant drugs Insulin Nicotinic acid Norpace Penicillin Streptomycin Sulfa drugs Tagamet (Cimetadine) Tetracycline Tranquilizers 2. Please list all medications you are currently taking (please include dosage and frequency): 4.
5 YES NO I. Social History: 1. Do you smoke? if yes, how many cigarettes do you smoke each day? Have you tried ever quiting? 2. Do you consume alcoholic beverages (if yes, how often)? 3. How many cups of coffee or caffeine-containing beverages do you drink each day? 4. Do you use any of the following substances: Amphetamines Quaaludes Marijuana Cocaine LSD Angel dust Heroin Methadone 5. Do you excercise? Primary activity: Duration/day: How many years?_ J. Family History: 1. Was your mother ever given diethylstilbesterol (DES)? 2. How many sisters do you have? Please give the number of children of each of your sisters: sister #1 sister #2 sister #3 sister #4_ 3. How many brothers do you have? Please give the number of children of each of your brothers: brother #1 brother #2 brother #3 brother #4_ 4 Are any of the following diseases or conditions present in your family? birth defects Bowel disorders Cancer Cystic fibrosis Diabetes Extra fingers or toes Heart disease High blood pressure Hormone problems Kidney disease Lung disease Poor sense of smell Tuberculosis Ulcers Other K. CAM Experience(Results) 1. Have you ever been treated with: Good Fair Poor Acupuncture Ayurveda Chiropractic Medicine Electromagnetic therapy Herbal therapy Homeopathy Hypnosis Massage Therapy Naturopathy 2. Color preference (please circle one):blue-green, Red, Earth tones (tan,yellow-brown), White, Black 3. Flavor preference (please circle one):sour, Bitter-Roasted, Sweet, Spicy, Salty 4.Seasonal preference (please circle one):spring, Summer, Fall-Autumn, Winter 5.
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Adult Health History Legal Name: First Last Name you like to be called: Date of Birth: Legal sex: Male Female X Gender: Woman Man Trans Woman Trans Man Non-binary Genderqueer Agender Not Listed: Filling
New Patient Questionnaire
New Patient Questionnaire Welcome to Mass General/North Shore Cardiology. Please fill out the following questionnaire, answering each question to the best of your ability. The information will assist your
What to do about infertility?
What to do about infertility? Dr. M.A. Fischer Section Head, Division of Urology, Department of Surgery Assistant Clinical Professor, Department of Obstetrics and Gynecology Hamilton Health Sciences, Hamilton,
Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)
Patient Registration: Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA 91361 (805) 496-8522 Fax (805) 496-0469 Last Name: First Name: MI: Address: City:
WOMEN & INFANTS HOSPITAL 101 Dudley Street Providence, RI CENTER FOR REPRODUCTION AND INFERTILITY INFERTILITY QUESTIONNAIRE.
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Patient Name: DOB: Age: M/F. SS# Single Married Separated Divorced Widowed. Spouse Name: DOB: M/F
CALIFORNIA HEMATOLOGY ONCOLOGY MEDICAL GROUP Wade Nishimoto, MD. Alex Makalinao, MD. Frank Mori, MD. Allan Orenstein, MD. Jenny Ru, MD Patient Name: DOB: Age: M/F Home Address: City: State: Zip: Do you
Form.NewPatientHstory_PrecisionEndoRev Page 1 of 5
Patient s Name (First, Middle, Last): Address: City: State: Zip Code: Email: Main Contact#: Alternate#: Work#: Date of Birth: / / Sex: Male Female SS# (optional): Marital Status : Single Married Divorced
An affiliate of Saint Mary's Health System FRANKLIN MEDICAL GROUP, PC. NEW PATIENT INTAKE FORM. Last Name: First Name: DOB: Age:
FRANKLIN MEDICAL GROUP, PC. NEW PATIENT INTAKE FORM Last Name: First Name: DOB: Age: Date of Service: Present Occupation: Marital Status: Married Divorced Single Widowed Partnered List household Members
Fertility HEALTH HISTORY
Fertility HEALTH HISTORY Female Name: First Middle Initial Last Preferred name Male Name: First Middle Initial Last Preferred name Address: City: State: Zip code: Contact numbers: home work/cell: Please
Patient Information. Marital Status (Single, Married, Life Partner, Divorced, Widowed) CHIEF COMPLAINT
Patient Information Name Date Home Address City State Zip Phone E-mail Address Cell Phone: Business Address City State Zip Phone Occupation Place of Birth Date of Birth Age Height Weight Soc. Sec. # Sex