Patient Intake Form

New Patient Intake form:

Version 06.08.23

Patient Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Contact

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Pharmacy Details

Pharmacy Name

Street Address

CityState / Province

Postal / Zip Code
Pharmacy Phone Number

Area CodePhone Number
Comments

History of Present Illness
Height*
Weight*
Which best describes the main reason for TODAY'S visit?*

Blood in the urine (including microscopic)Constipation or Fecal IncontinenceEjaculatory issue (premature ejaculation/hematospermia)Elevated PSAExposed Vaginal MeshGU Fistula (including vesicovaginal fistula/rectovaginal fistula)Hydronephrosis or kidney cystInfertilityKidney/ureter/bladder stoneLow TestosteroneMenopauseNeurogenic bladderPelvic organ prolapse (including cystocele/rectocele)Pelvic or Vaginal PainPenile Girth EnhancementPenile Issue (including balanitis/phimosis/circumcision consult/Peyronie's/condyloma)Sexual or Erectile dysfunction (all genders, including decreased libido and sensation)Swelling or pain of the scrotum or testicles (including hydrocele, spermatocele, varicocele, epididymitis)Urinary symptoms (including frequency, urgency, straining, retention, leaking, incontinence, BPH)Urethral DiverticulaUrethral prolapse/caruncleUrinary Tract Infection or Prostatitis or Interstitial CystitisVasectomyOther
Choose any other conditions you want to discuss at FUTURE visits (select all that apply)

Blood in the urine (including microscopic)Constipation or Fecal IncontinenceEjaculatory issue (premature ejaculation/hematospermia)Elevated PSAExposed Vaginal MeshGU Fistula (including vesicovaginal fistula or rectovaginal fistula)Hydronephrosis or kidney cystInfertilityKidney/ureter/bladder stoneLow TestosteroneMenopauseNeurogenic BladderPelvic organ prolapse (including cystocele or rectocele)Pelvic or vaginal painPenile Girth EnhancementPenile Issue (including balanitis/phimosis/circumcision consult/Peyronie's/condylomaSexual or Erectile dysfunction (all genders, including decreased libido and sensation)Swelling or pain of the scrotum or testicles (including hydrocele, spermatocele, varicocele, epididymitis)Urethral DiverticulaUrethral prolapse/caruncleUrinary symptoms (including frequency, urgency, straining, retention, leaking, incontinence, BPH)Urinary Tract Infection or Prostatitis or Interstitial CystitisVasectomyOther
Are you allergic to the following? (Select all that apply)*

LatexShellfishBand-aids/AdhesivesIVP DyeIodineNo known allergiesOther
List all MEDICATION ALLERGIES (Name of Medication-Reaction to Medication)
List all HOSPITALIZATIONS, including the year (not ER visits)
List all SURGERIES. (Select all that apply)

AppendectomyArtificial urinary sphincterBladder surgeryBladder botoxBowel surgeryCholecystectomy/gall bladder removalCystectomy/bladder removalGender affirmation surgeryHypospadias repairHysterectomyKidney stone removalKidney surgeryMid-urethral slingNephrectomy/kidney removal surgeryOopherectomy/ovary removalPenile implantPenile surgeryProstatectomyProstate surgerySacral neuromodulation (Interstim®, Axonics®)Scrotal surgeryTesticular surgeryTURPUrethral surgeryVaginal prolapse surgeryVaginal surgeryVasectomy
List all surgeries not mentioned above. (Please specify)
Please select if you have been diagnosed with or have a history of any of the following conditions:

abnormal pap smearacute coronary syndromeAIDS/HIVanxietybenign prostatic hyperplasiabladder cancerbreast cancercerebrovascular accidentcervical cancerchronic bladder infectionschronic obstructive pulmonary diseasecongestive heart failureconstipationdeep vein thrombosisdepressiondiabeteselevated PSAendometrial cancerendometriosisend-stage renal diseaseerectile dysfunctionestrogen replacement therapyfecal incontinencefibromyalgiahypertensionhypogonadisminflammatory bowel diseaseirritable bowel syndromekidney stoneskidney transplantmenopausemultiple sclerosismyocardial infarctionobstructive sleep apneaosteoarthritisovarian cancerpelvic organ prolapseprostate cancerpulmonary embolismrenal cell cancersickle cell diseasesickle cell traittesticular cancerurethral diverticulumurinary incontinenceurinary tract infectionurostomyvulvodyniaOther
OTHERS (Please list down all the past medical conditions)

Please List All Medications*

	Medication Name	Dosage Amount	#Taken Daily	Ordering Doctor	Start Date
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Tobacco Usage:*

Yes, I Smoke DailyYes, Sometimes I SmokeNo, I Quit SmokingNo, I Never Smoked
How many packs per day?
How many years?
Have you tried to quit?
Alcohol Consumption*

I don't drink1-4 drinks/month1-2 drinks/day3-4 drinks/day5+ drinks/day
Caffeine Consumption*

I don't use caffeine1-4 cups/month1-2 cups/day3-4 cups/day5+ cups/day
Number of Pregnancies
Number of children born
Are you currently pregnant?
Marital Status*

SingleMarriedSeparatedDivorcedWidowedLiving with significant otherNot answered
What is your current living arrangement?*

Live aloneLive with family/friendAssisted livingNursing home
Do you have an Advanced Directive?*

YesNo
Do any one of your family members have any of the following:*

Genitourinary (kidney/prostate/bladder/testicle) cancerBreast cancerKidney stonesUrinary stonesSickle cell anemiaNot applicable

	Yes	NO
Abdominal Pain
Back Pain
Black Stool
Bloody Stool
Blurred Vision
Bone Pain
Changes in Appetite
Changes in Vision
Chest Pain
Chills
Cold Intolerance
Cough
Decreased Urinary Stream
Deep Vein Thrombosis (Clots)
Dermatitis
Diarrhea
Easy Bleeding
Easy Bruising
Excessive Thirst
Fatigue
Fever
Frequent Urination at Night
Frequency of Urination
Headaches
Heart Murmurs
Heat Intolerance
Impotence
Incontinence
Irregular Heartbeat
Joint Pain
Lack of Coordination
Lumps in Chest/Breasts
Muscle Pain
Nasal Congestion
Nausea
Nipple Discharge
Numbness or Tingling
Painful Urination
Pelvic Pain
Post-Void Dribbling
Rapid Ejaculation
Seizures
Scrotal Pain
Shortness of Breath
Sinus Pain
Skin Rash
Swelling in Chest/Breast
Tenderness in Chest/Breast
Urgency
Vaginal Pain
Vomiting
Weight Gain
Weight Loss
Wheezing

New Patient Intake form: