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Patient history form


RAO V.SUNKAVALLY M.D.,F.A.C.S.
PATIENT HISTORY FORM UROLOGY (Sheet 1/5 of NewPt H&P Revised 2/2011)
LAST NAME_________________________________ FIRST NAME_____________________ TODAY’S DATE__________TIME_____
DATE OF BIRTH__________________ REFERRING DOCTOR_____________________________ LAST EXAM DATE ____________
CHIEF COMPLAINT: What is the main reason for your visit today? ( Describe your problem in detail including duration)
______________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
HISTORY OF PRESENT ILLNESS: Note: Please answer the following questions in detail!
1.Location of the problem:
Other____________________________________
2.Quality: Is the problem Constant or Variable?
Dull, then Sharp
Very Sharp then leaves
Always there
Other_______________________________________________
3.Severity: On a Scale of 1-10, with 10 being the most severe, Check the number that best describes the severity of problem?
4.Duration: When did you first notice the problem?
Two days ago
2 weeks ago
2 months ago
Other___________________________________________________________
5.Timing: How long does the problem last?
It is always there
Other______________________________
6.Context: Does the problem interfere with your normal functions?
No If Yes, please explain_______________________________________________________________________________
7.Modifying Factors: Does anything help or make the problem worse?
Moving around
Standing up
Lying on my side
Other______________________________________________________
8.Associated Signs & Symptoms: Is there anything else occurring at the same time?
No. If Yes please explain below:
Headaches
Other________________________________________________________________________
PAST, FAMILY & SOCIAL HISTORY
Medications: Please list all medications you are currently taking.
DRUG
NAMES DOSE START DATE DRUG NAMES DOSE START DATE
________________________ _____________ ____________ _______________________ _____________ ______________
________________________ _____________ ____________ _______________________ _____________ ______________
________________________ _____________ ____________ _______________________ _____________ ______________
________________________ _____________ ____________ _______________________ _____________ ______________
PAST MEDICAL HISTORY:List any personal past Illnesses and or Surgeries and when they occurred.

ILLNESS OR SURGERY DATE ILLNESS OR SURGERY DATE
Hypertension.
High cholesterol. ____________
___________________________________ ____________ ___________________________________________ ____________ ___________________________________ ____________ ___________________________________________ ____________ ___________________________________ ____________
ALLERGIES: Do you have any allergies to medicines or food ? No Yes. IF YES, PLEASE LIST BELOW:
PENICILLIN.
MACRODANTIN.
OTHER: _____________________________________________________
FAMILY HISTORY: List all serious Illnesses in your Immediate family.

YES NO RELATION YES NO RELATION
YES NO RELATION/ TYPE OF CANCER
Heart Disease
____________ Diabetes
____________ Cancer
_____________________________
High Blood Pressure
____________ Stroke
____________ Other
_____________________________
Do you Drink Alcohol? No Yes. What do you drink?_________________ How much?______________ Quit Date:__________
Do you Smoke Cigarettes? No Yes.How much?______________ Quit date:_________ How long were you smoking?______

PHYSICIAN USE ONLY:(Comment/Notes)____________________________________________________________________________________

________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________

NEW PATIENT HISTORY OF PRESENT ILLNESS (1-3 = 1 or 2; 4+ = 3-5)PFSH ( 0 = 1 or 2; 1-2 = 3; 3 = 4 or 5) Page 1 OVER

RAO V.SUNKAVALLY M.D.,F.A.C.S. REVIEW OF SYSTEMS
UROLOGY (sheet 2/5 of NewPt H&P Revised 2/2011)
Do you now have or have you had any of the following problems? Please explain any “Yes” answer
CONSTITUTIONAL SYMPTOMS:
1.Fever
Y 2.Chills
Y 3.Weight loss
Y 4.Headaches
Y 5.Other __________________________________
_____________________________________________________________________________________________________________
EYES:

1.Blurred Vision

Y 2.Double Vision
Y 4.Other _____________________________________________
_____________________________________________________________________________________________________________
EARS/NOSE/MOUTH/THROAT:

1.Hearing loss

Y 2.Hay fever
Y 3.Loss of Smell
Y 4.Sinus Problem
Y 5.Other__________________
_____________________________________________________________________________________________________________
CARDIOVASCULAR:
1.Chest Pains
Y 2.Irregular Heart Beat
Y 3.Varicose Veins
Y 4.Other _________________________________
_____________________________________________________________________________________________________________
RESPIRATORY:

1.Wheezing

Y 2.Frequent Cough
Y 3.Shortness of Breath
Y 4.Other ________________________________
_____________________________________________________________________________________________________________
GASTROINTESTINAL:

1.Abdominal Pain

Y 2.Nausea/Vomiting
Y 3.Constipation
Y 4.Other_________________________________
_____________________________________________________________________________________________________________
GENITOURINARY:

1.Urine Retention

Y 2.Painful Urination
Y 3.Blood in Urine
Y 4.Other_________________________________
_____________________________________________________________________________________________________________
MUSCULSKELETAL:

1.Joint Pain

Y 2.Neck Pain
Y 3.Back Pain
Y 4.Back Injury
Y 5.Other___________________________
_____________________________________________________________________________________________________________
INTEGUMENTARY:

1.Skin Rash

Y 2.Persistant Itch
Y 3.Boils
Y 4.Other______________________________________________
_____________________________________________________________________________________________________________
NEUROLOGICAL:

1.Tremors

Y 2.Dizziness
Y 3.Numbness/Tingling
Y 4. Other_______________________________________
_____________________________________________________________________________________________________________
PSYCHIATRIC:

1.Depression

Y 2.Anxiety
Y 3.Suicidal Tendencies
Y 4.Other______________________________________
_____________________________________________________________________________________________________________
ENDOCRINE:
1.Excessive Thirst

Y 2.Too Hot/Cold
Y 3.Tired/sluggish
Y 4.Other___________________________________
_____________________________________________________________________________________________________________
HEMATOLOGIC/LYMPHATIC:

1.Swollen Glands

Y 2.Blood clotting Problem
Y 3.Anemia
Y 4.Other________________________________
_____________________________________________________________________________________________________________
ALLERGIC/IMMUNOLOGIC:

1.Hay Fever

Y 2.Other____________________________________________________________________________________
PHYSICIAN USE ONLY: (Comments/Notes)____________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
NEW PATIENT REVIEW OF SYSTEMS (0-1 = 1 or 2; 2-9 = 3; 10+ = 4 or 5 ) PHYSICIAN SIGNATURE OR INITIALS______________
DATE:______________

Source: http://www.sunkavallymd.com/webdocuments/health-history-urology-form.pdf

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