PATIENT HEALTH QUESTIONNAIRE: Urology

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1 PATIENT HEALTH QUESTIONNAIRE: Urology Patient Name: Sex: M F Last, First, Middle Initial Date of Birth: \ \ Age: Social Sec #: - - Type of visit: Consultation requested by another Physician Self-referred Second Opinion A. PHYSICIAN INFORMATION Were you referred to USF Health by a physician? Yes No Primary Care MD: Referring Physician: Specialty: Are there any other physicians to whom you want your progress reports sent? If so, please indicate below: Name of Physician: Specialty: Name of Physician: Specialty: B. CHIEF COMPLAINT (the main reason for seeking medical attention at USF Health): C. HISTORY OF PRESENT ILLNESS Briefly describe your symptoms, when they started and treatment you have received. D. PAST MEDICAL HISTORY Adult Illnesses: Have you ever had any of the following? (Please check) Gout High Blood Pressure Diabetes/sugar (diet controlled) Syphilis Rheumatic Fever Rheumatoid Arthritis (disfigured joints) Nervous Breakdown Stomach Ulcers Degenerative Arthritis (joints appear normal) Depression Hepatitis Thyroid Disease Epilepsy (seizures) Cirrhosis Cancer Cataracts Colitis Anemia (low blood) Stroke or Paralysis Diverticulitis Asthma Bronchitis Gallstones Tuberculosis (TB) Emphysema Pancreatitis Hay Fever Heart Disease Kidney Stones Pneumonia Angina (chest pain) Gonorrhea Pleurisy (chest pain) Bleeding Disorder 1

2 E. PAST SURGICAL HISTORY OPERATION PERFORMED MONTH/YEAR REASON FOR OPERATION Did you ever have the following treatments or procedures? NO YES IF YES, PLEASE EXPLAIN Radiation Therapy Why? Number of Treatments? Were where treatments done? (Name of hospital) Chemotherapy Why? Which drugs? Were where treatments done? (Name of hospital) Blood Transfusion F. FAMILY HISTORY NO YES IF YES, PLEASE EXPLAIN History of Cancer Hereditary Diseases History of Kidney Stones G. SOCIAL HISTORY EDUCATION: Check last year completed: Grade School High School College OCCUPATION: Check one or more: Why? Self-employed Housewife If employed or self- employed, type of work you do: Employed (by others) Retired Student Unemployed If disabled, describe disability and date work stopped: MARITAL STATUS: Single Married Divorced Separated Widowed H. SOCIAL ISSUES Do you live alone? YES NO If no, who lives with you? Do you drive? YES NO If no, why? Do you need assistance with your activities of daily living? YES NO If yes, why? Do you have financial concerns? YES NO If yes, why? Are you concerned about your coping abilities, or your family s ability to cope? YES NO If yes, why? Are there martial concerns? YES NO If yes, why? 2

3 I. REVIEW OF SYSTEMS In the last three (3) months, have you experienced any of the following: Constitutional Fever Chills Any weight change? YES NO If yes, was it: Gain Loss How many pounds? Height Weight Present Usual SKIN NO YES IF YES PLEASE EXPLAIN 1. Chronic or recurring skin lesions 2. Easy Bruising tendencies 3. Change in skin color EYES NO YES 4. Pain in Eyes 5. Eye injury 6. Double vision 7. Blurry vision 8. Wears Glasses EARS NO YES 9. Tinnitus/Buzzing or ringing in ears 10. Sensation of spinning 11. Loss of hearing 12. Ear Aches 13. Discharge from ears NOSE AND THROAT NO YES 14. Sore throats 15. Hoarseness 16. Nosebleeds 17. Mouth ulcers 18. Bleeding gums 19. Sinus Trouble 20. Swollen lymph nodes or glands LUNG NO YES 21. Blood in sputum 22. Wheezing/asthma 23. Cough 24. Respiratory infections/pneumonia 25. Shortness of Breath 26. Do you smoke cigarettes? If yes, # packs per day: How many years? 27. Have you ever smoked for a period If yes, # packs per day: of five or more years? How many years? 28. Are you an ex-smoker? If yes, when did you quit? HEART NO YES 29. Calf cramps 30. Palpitations/Unusual heartbeat 31. Ankle joint swelling 32. Inadequate exercise 33. Fainting 34. Chest pain/discomfort/tightness/angina 35. Sleeping with multiple pillows 3

4 GASTROINTESTINAL NO YES 36. Stomach pain 37. Blood in stool 38. Frequent heartburn or indigestion 39. Nausea or vomiting 40. Black, tarry stools 41. Diarrhea 42. Difficulty Swallowing 43. Constipation 44. Decreased appetite 45. Change in stools 46. Regular alcohol/beer intake? BONES AND MUSCLES NO YES 47. Painful joints 48. Sore muscles 49. Back pain 50. Clumsiness of hands or feet 51. Muscle weakness 52. Unusual fatigue NEUROLOGY NO YES 53. Frequent or severe headaches 54. Dizziness or faintness 55. More nervous than average person 56. Numbness/tingling 57. Memory lapses or loss WOMEN ONLY NO YES 58. Painful Intercourse 59. Vaginal Discharge 60. Blood in Urine 61. Blood at Beginning of Urine Stream 62. Blood at Middle of Urine Stream 63. Blood at End of Stream 64. Blood Clots in Urine 65. Mass in Abdomen 66. Mass or Bulge in Pelvis 67. Painful Urination 68. Other Age at first menstruation: Number of Pregnancies: Date of last period: Number of Live Births: Irregular or excessive periods: No Yes Ever use hormones? No Yes How long? Gone through menopause? No Yes When? MEN ONLY NO YES 58. Painful Intercourse 59. Penile Discharge 60. Blood in Urine 61. Blood at Beginning of Urine Stream 62. Blood at Middle of Urine Stream 63. Blood at End of Stream 64. Blood Clots in Urine 65. Mass in Abdomen 66. Mass or Bulge in Pelvis 67. Bulge inside Scrotum 68. Painful Urination 69. Other 4

5 K. MEDICATIONS List any medications you are now taking (including vitamins and all non-prescription drugs). Copy names and dosages of medication from the prescription label. Please bring all medications with you to your first visit. NAME OF MEDICATION HOW OFTEN DOSE (MGS, tablets) L. ALLERGIES Please list all medications to which you are allergic. Include any reactions you have had to x-ray dyes (iodine) MEDICATION TYPE OF REACTION Name of Local Pharmacy: Address/Location of Pharmacy: Phone number: Mail Order Pharmacy Name: Mail Order Pharmacy Phone Number: Mail Order Pharmacy Fax Phone Number: Mail Order Pharmacy ID #: Other Medications/Allergies: Please list any questions you would like to ask us: 5

6 USF Health Department of Urology American Urological Association System Score Sheet (AUASS) OVER THE PAST MONTH OR SO (Check the appropriate number): Almost Some Less than Half of the More than Almost never of the time half the time time half the time always 1. How often have you had a sensation of not emptying your bladder completely after you finished urinating? 2. How often have you had to urinate again less than 2 hours after you finished urinating? 3. How often have you found you stopped and started again several times when you urinated? 4. How often have you found it difficult to postpone urination? 5. How often have you had a weak stream? 6. How often have you had to push or strain to begin urination? 7. How MANY times did you typically get up at night to urinate from the time you went to bed until getting up? Bother = Sum of Question 1-7 Quality of life due to urinary problems 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 it? Circle one (1) Delighted (5) Mostly dissatisfied (2) Pleased (6) Unhappy (3) Mostly Satisfied (7) Terrible (4) Mixed (about equally satisfied and dissatisfied) AFFIX PATIENT LABEL HERE 6

7 USF Health Department of Urology SEXUAL HEALTH INVENTORY FOR MEN (SHIM) PATIENT NAME: TODAY S DATE PATIENT INSTRUCTIONS Sexual health is an important part of an individual s overall physical and emotional well-being. Erectile dysfunction, also known as impotence, is one type of very common medical condition affecting sexual health. Fortunately, there are many different treatment options for erectile dysfunction. This questionnaire is designed to help you and your doctor identify if you may be experiencing erectile dysfunction. If you are, you may choose to discuss treatment options with your doctor. Each question has several possible responses. Circle the number of the response that best describes your own situation. Please be sure that you select one and only one response for each question. OVER THE PAST 6 MONTHS: 1. How do you rate your confidence that you could get and keep an erection? 2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)? 3. During sexual intercourse, how often were you able to maintain your erection? 4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? 5. When you attempted sexual intercourse, how often was it satisfactory for you? No Sexual Activity Did Not Attempt Intercourse Did Not Attempt Intercourse Did Not Attempt Intercourse Very Low Low Moderate High Very High Almost Never or Never A Few Times (much less than half the time) Sometimes (About half the time) Most Times (Much More Than Half the Time) Almost Always or Always Almost Never or Never A Few Times (much less than half the time) Sometimes (About half the time) Most Times (Much More Than Half the Time) Almost Always or Always Extremely Difficult Very Difficult Difficult Slightly Difficult Not Difficult Almost Never or Never A Few Times (much less than half the time) Sometimes (About half the time) Most Times (Much More Than Half the Time) Almost Always or Always Add the numbers corresponding to questions 1-5. TOTAL: The Sexual Health Inventory for Men further classifies ED severity with the following breakpoints: 1-7 Severe ED 8-11 Moderate ED Mild to Moderate ED Mild ED AFFIX PATIENT LABEL HERE 7

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