Hypospadias - Medical History

1

Patient Name* This field is required.

First Name

Last Name

2

Birth Date* This field is required.

3

Primary Care Physician

First Name

Last Name

4

Referring Physician (if different from Primary Care Physician)

First Name

Last Name

5

Chief ComplaintReason for appointment:

6

What would you like to talk about or have happen today?

7

Has the patient had Bladder/Kidney/UTIs?

YESNO

8

Has the patient had any fever with these infections?

YESNO

9

Does the patient have pain when urinating?

YESNO

10

Have you seen blood in the urine?

YESNO

11

Has a test shown blood in the urine?

YESNO

12

Has the patient had problems with constipation?

YESNO

13

Is the patient toilet trained?

YESNO

14

Does the patient leak urine during the day?

YESNO

15

Does the patient get up to urinate at night?

YESNO

16

Does the patient wet the bed?

YESNO

17

Does the patient get warning about needing to urinate?

YESNO

18

How often does the patient urinate during the day?

19

Other medical problems (list):If there isn't, click next

21

Other (please list):If there none, click next

22

Descriptions:

23

Please provide the patient's most recent weight in either kilograms (kg) or pounds (lb), please identify which unit of measurement.* This field is required.ex. 75kg or 165.3lb

24

Please provide the patient's most recent height in either centimeters (cm) or inches (in), please identify which unit of measurement.* This field is required.ex. 180cm or 70.8in

25

Please identify any food, drug, or environmental allergies the patient suffers from. If none please put "N/A".

26

Please identify any medications the patient is taking. If none please put "N/A".

27

For any prescribed medications, are pills or liquid preferred? Please keep in mind that without BOTH a height and weight, medication cannot be prescribed.

Pill medication

Liquid medication

28

Did the patient or family have any recent illnesses or come into contact with a known COVID positive individual?

YESNO

29

Are immunizations UP TO DATE?

YESNO

30

Is the patient allergic to any medications?

YESNO

31

Please list:

32

Please list reactions:

33

Is the patient allergic to LATEX?

YESNO

34

Is the patient taking prescribed medications?

YESNO

35

Please list:

36

Is the patient taking any non-prescribed medications (j.e. herbals, or alternative medications)?

YESNO

37

How many times per day?

38

Please list:

39

Do any family members have any kidney/urologic problems?

YESNO

40

Please list which family member and problem:

41

Does the PATIENT suffer from any of the following medical conditions?* This field is required.

History of Keloiding/Abnormal scarring

History of Eczema

IUGR

Was Testosterone given by another doctor (a shot or cream)

Was he born premature (less than 37 weeks)

None of the Above

Other

42

Please explain in more detail. For testosterone please identify the details of usage and if premature please clarify weeks.

43

Does the patient's FAMILY suffer from any of the following medical conditions?* This field is required.

Keloiding/Abnormal Scarring

Prenatal Progesterone involving the patient

None of the above

44

Please explain in more detail by providing the family member that struggles with scarring as well as how many weeks pregnant progesterone was used for.

45

Has the patient ever been hospitalized?

YESNO

46

If yes, please give reason and dates of hospitalization.

47

Has the patient had previous surgeries related to the condition being treated at Hypospadias Specialty Center?

YESNO

48

Please list out the following information: number of surgeries the above patient has had, the surgeon's name, the location of surgery (city and state) and the dates of surgery (if known). This is to verify we have all the correct notes on file in the patient's chart.

49

Has hyperbaric oxygen therapy (HBOT) been recommended to you?

YESNO

50

Please provide the facility you have chosen for HBOT.

51

Signature* This field is required.By signing below, I agree that all the above information is accurate.

Clear

52

Full Name of Signer* This field is required.

First Name

Last Name

53

Today's Date

Date