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Impotentie brengt een constant ongemak met zich mee, net als fysieke en psychologische problemen in uw leven cialis kopen terwijl generieke medicijnen al bewezen en geperfectioneerd zijn

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