Female Questionnaire-------ANSWER
What is your reason for seeing the doctor?
(Please Circle) Notes On Present Illness:
[Yes] [No] Have You Been Seen Previously In This Office?
[Yes] [No] Pain or burning with urination?
[Yes] [No] Blood in urine at any time?
[Yes] [No] Slow urinary stream?
[Yes] [No] Difficulty starting urination?
[Yes] [No] Incontinence or inability to hold urine (wet pants)?
[Yes] [No] Urinating too frequently (more than 6 times a day)?
[Yes] [No] Awakening at night to urinate more than once?
[Yes] [No] Bedwetting?
[Yes] [No] Urinary tract infection [Kidney] [Bladder]
[Yes] [No] Kidney stone?
[Yes] [No] Recent fevers or chills?
[Yes] [No] Have you been to a urologist before?
[Yes] [No] Have you had kidney or bladder x-rays before?
[Yes] [No] Are your periods normal? If not describe…..
[Yes] [No] Recent vaginal discharge
[Yes] [No] Use of birth control pills/hormones [Now] [In past]
----------------Do not write in enclosed space-------------------------
HPI
Location
Quality
Severity + ++ +++ ++++
Duration
Timing
Content
Modifying factors
Associated signs and sxs
CONTINUE ON TO THE
Please fill in all drugs or medications that you are allergic to or cannot tolerate
Allergies |
(list all allergies) |
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Please fill in
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Date |
Drug Name |
Dosage |
Refill Date |
Refill Date |
Refill Date |
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Continue to next page
Do you take aspirin or any aspirin-containing drugs [Yes] [No]
Do you take over the counter medications [Yes] [No] If yes, list on drug page #2
List all previous operations or surgeries
___________________ _____________________ __________________ _________________
List all previous serious illnesses or injuries
___________________ _____________________ __________________ _________________
Has anyone in your family had any hereditary disease [yes] [no]
Do you smoke cigarettes? [Yes] [No] If yes, how many packs per day?______
If you have stopped, when did you stop?_________________
Do you drink alcoholic beverages? [never] [occasional] [moderate] [heavy]
Occupation_________________ [retired] Hobbies/FreeTime___________________________
Have you had problems with . . .? (circle if [Yes])
[Yes] [No] Eyes/Ears [Yes] [No] Arthritis
[Yes] [No] Mouth/Throat [Yes] [No] Joint problems
[Yes] [No] Heart attack [Yes] [No] Back problems
[Yes] [No] Heart murmur [Yes] [No] Anemia
[Yes] [No] Irregular heart rhythm [Yes] [No] Bleeding tendency
[Yes] [No] Chest pain [Yes] [No] Psychiatric problems
[Yes] [No] High blood pressure [Yes] [No] Depression
[Yes] [No] Shortness of breath [Yes] [No] Seizure/epilepsy
[Yes] [No] Cough [Yes] [No] Stroke
[Yes] [No] Asthma [Yes] [No] Headache
[Yes] [No] Stomach pain [Yes] [No] Weight loss or gain
[Yes] [No] Ulcer [Yes] [No] Chronic pain
[Yes] [No] Diarrhea [Yes] [No] Sweats
[Yes] [No] Constipation [Yes] [No] Diabetes
[Yes] [No] Blood in stool [Yes] [No] Thyroid problems
[Yes] [No] Skin problems [Yes] [No] Breast problems
How many pregnancies?___________ How many children born alive ________________
When was your last