Michael J. Young, M.D. Paul M. Yonover, M.D.

PATIENT HISTORY FORM

Date:__________________________________

Last Name:___________________ First Name:___________________ M.I.____

Date of Birth: _________________ Occupation:__________________________
Referring Physician:_________________________________________________

Chief Complaint:

What is the main reason for your visit? _________________________________________________ __________________________________________________________________________________________________________________________________________________________________

History of Present Illness

Location: of the problem_____________________________________________________________

Severity__________________________________________________________________________

Duration of problem or condition, has it changed?_________________________________________

Does anything make the condition better or worse?________________________________________

Does the problem come and go, or is it constant? Please describe_____________________________

_________________________________________________________________________________

Does the problem interfere with your normal activities?____________________________________

Past Medical History

____ Heart attack ____ HIV ____ Stroke ____ Artificial heart valve ____Glaucoma

____ Easy bruising / bleeding ____ High blood pressure ____ Rheumatic fever ____ Diabetes ____ Sickle cell disease/trait

Allergies NONE ______	Current Medications NONE _______
(medications, food, latex, iodine) _____________________________ _____________________________	_____________________________ _____________________________ _____________________________

Previous Surgery / Year

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Habits

Do you smoke? Yes [] No [] If yes, how much? ______________________

Do you use alcohol? Yes [ ] No [ ] If yes, how much? ______________________

Have you ever been a heavy user of alcohol? Yes [ ] No []

Do you use recreational drugs? Yes [ ] No [ ]

Family History

Is there any history in your family of the following?

Heart attack [] Heart failure [] High blood pressure [] Stroke [] Cancer [] Diabetes [ ]

Page 2

Systems Review

Weight ___________ Height______________

Childhood immunizations up to date? Yes [ ] No []

Do you now or have you had any problems related to the following systems? Circle Yes or No. Please explain any Yes answers.
Constitutional Symptoms			Integumentary
Fever	Y	N	Skin rash	Y	N
Chills	Y	N	Boils	Y	N
Headache	Y	N	Persistant itch	Y	N
Other			Other
Eyes			Musculoskeletal
Blurred vision	Y	N	Joint pain	Y	N
Double vision	Y	N	Neck pain	Y	N
Pain	Y	N	Back pain	Y	N
Other			Other
Allergic/Immunologic			Ear/Nose/Throat/Mouth
Hay fever	Y	N	Ear infection	Y	N
Drug allergies	Y	N	Sore throat	Y	N
Other			Sinus problems	Y	N
			Other
Neurological			Genitourinary
Tremors	Y	N	Urine retention	Y	N
Dizzy spells	Y	N	Painful urination	Y	N
Numbness/tingling	Y	N	Urinary frequency	Y	N
Other			Other
Endocrine			Respiratory
Excessive thirst	Y	N	Wheezing	Y	N
Too hot/cold	Y	N	Frequency cough	Y	N
Tired/sluggish	Y	N	Shortness of breath	Y	N
Other	Y	N
Gastrointestinal			Hematologic/Lymphatic
Abdominal pain	Y	N	Swollen glands	Y	N
Nausea/vomiting	Y	N	Blood clotting problem	Y	N
Indigestion/heartburn	Y	N	Other
Other
Cardiovascular			Psychologic
Chest pain	Y	N	Are you generally satisfied with your life?	Y	N
Vancose veins	Y	N	Do you feel severely depressed?	Y	N
High blood pressure	Y	N	Have you considered suicide?	Y	N
Other			Other

Other problems which you believe are important
__________________________________________________________________________________________________________________________________________________________________

International Prostate Symptom Score (I-PSS)

Patient's Name _________________________ Date of Birth____________ Date Completed_______________

	Not at all	Less than 1 time in 5	Less than half the time	About half the time	More than half the time	Almost always	Your score
1. Incomplete Emptying Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating?	0	1	2	3	4	5
2. Frequency Over the past month, how often have you had to urinate again less than two hours after you finished urinating?	0	1	2	3