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	4	5
3. Intermittency Over the past month, how often have you found you stopped and started again several times when you urinated? .	0	1	2	3	4	5
4. Urgency Over the past month, how often have you found it difficult to postpone urination?	0	1	2	3	4	5
5. Weak Stream Over the past month, how often have you had a weak urinary-stream?	0	1	2	3	4	5
6. Straining Over the past month, how often have you had to push or strain to begin urination?	0	1	2	3	4	5
	None	1 time	2 times	3 times	4 times	5 times or more
7. Nocturia Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?	0	1	2	3	4	5
Total-PSS Score
	Delighted	Pleased	Mostly satisfied	Mixed	Mostly dissatisfied	Unhappy	Terrible
Quality of Life Due to Urinary Symptoms If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?	0	1	2	3	4	5	6

The International Prostate Symptom Score (I-PSS) is based on the answers to seven questions concerning urinary symptoms. Each question allows the patient to choose one of six answers indicating increasing severity of the particular symptom. The answers are assigned points from 0 to 5 The total score can therefore range from 0 to 35 (asymptomatic to very symptomatic). Furthermore, the International Scientific Committee recommends the use of a question to assess the quality of life. The answers to this question range from "delighted" to "terrible" or 0 to 6. Although this single question mayor may not capture the global impact of benign prostatic hyperplasia (BPH) symptoms or quality of life, it may serve as a valuable starting point for doctor-patient conversation. The International Scientific Committee recommends that all physicians who counsel patients suffering from symptoms of prostatism utilize these measures not only during the initial interview but also during and after treatment in order to monitor treatment response.

The International Scientific Committee, under the patronage of the World Health Organization IWHOI and the International Union Against Cancer (UICCj,has agreed to use the symptom index for BPH, which has been developed by the American Urological Association (AUAI Measurement Committee, as thesymptoms assessment tool for patients suffering from prostatism.

The International Prostate Symptom Score (I-PSS) is based on the answers to seven questions concerning urinary symptoms and one question concerning quality of life. Each question concerning urinary symptoms allows the patient to choose one out of six answers indicating increasing severity of the particular symptom. The answers are assigned points from 0 to 5. The total score can therefore range from. 0 to 35 (asymptomatic to very symptomatic).

The questions refer to the following urinary symptoms:

Questions	Symptom
1	Incomplete Emptying
2	Frequency
3	Intermittency
4	Urgency
5	Weak Stream
6	Straining
7	Nocturia

Question eight refers to the patient's perceived quality of life.

The first seven questions of the I-PSS are identical to the questions appearing on the American Urological Association (AUA) Symptom Index which currently categorizes symptoms as follows:

Mild (symptom score less than or equal to 7)

Moderate (symptom score range 8-19)

Severe (symptom score range 20-35)

The International Scientific Committee (SCI), under the patronage of the World Health Organization (WHO) and the International Union Against Cancer (UICC), recommends the use of only a single question to assess the quality of life. The answers to this question range from "delighted" to "terrible" or 0 to 6. Although the single question mayor may not capture the global impact of benign prostatic hyperplasia (BPH) symptoms or quality of life, it may serve as a valuable starting point for a doctor-patient conversation.

The SCI has agreed to use the symptom index for BPH, which has been developed by

the AUA Measurement Committee, as the official worldwide symptoms assessment tool

for patients suffering from prostatism.

The SCI recommends that physicians consider the following components for a basic diagnostic workup: history; symptoms; physical exam; appropriate labs, such as UIA, creatinine, etc; and DRE or other evaluation to rule out prostate cancer. ¹
I. Adapted from: Recommendations of the International Scientific Committee. The evaluation and treatment of lower urinary tract symptoms (LUTS) suggestive of benign prostatic obstruction. Proceedings afthe 4th International Consultation on BPH. Paris; July 2-5,1997:3-6.

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