Symptom Checker

Appointment Date

Name *

First Name Middle Name Last Name

Today's Date *

Please complete the following form. It will allow us to expedite your visit and spend time on your urologic problem. Please list:

Any Current Illnesses *

Prior Urologic or Major Surgeries: *

Present Medications: *

Allergies to Medications: *

Significant Family Illnesses: *

Social History

Marital Status *

Married Unmarried Domestic Partnership

Do You Smoke? *

yes no

Do You Drink Alcohol? *

yes no

How Many Drinks Per Day?

Do you now, or have you ever had any problems related to the following systems? Please check the box for yes. Please explain any yes answers in the space provided below.

Constitutional Symptoms *

Weight Loss Headache Chills No Known Issues

Eyes *

Blurred Vision Double vision Pain No Known Issues

Neurological *

Tremors Dizzy spells Numbness/tingling No Known Issues

Endocrine *

Excessive thirst Too hot/cold Tired/sluggish No Known Issues

Gastrointestinal *

Abdominal pain Nausea/vomiting Indigestion/heartburn No Known Issues

Cardiovascular *

Chest pain Varicose veins High blood pressure No Known Issues

Allergy/Immunologic *

Hay fever Food allergies No Known Issues

Integumentary *

Boils Persistent itch No Known Issues

Musculoskeletal *

Joint pain Neck pain Back pain No Known Issues

Genitourinary *

Urinary retention Kidney stones Impotence Urinary infection No Known Issues

Respiratory *

Wheezing Cough Shortness of breath No Known Issues

Constitutional Symptoms *

Weight Loss Headache Chills No Known Issues

If you answered yes to any of the above, please explain as fully as possible.