Patient Questionnaire for Men
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- Osborn Alexander
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1 Patient Questionnaire for Men Please fill out the following questionnaire to the best of your ability prior to your first appointment. Your physical therapist will review your responses during your initial visit. Patient Name Date Name of primary care physician Referred to Physical Therapy by: What is the reason for your visit? How did you hear about Kamin Physical Therapy? doctor s referral; word of mouth; website; phone book; other: Urological History 1. Have you had problems or an infection in your prostate? 2. Have you had problems or an infection within your Testes? 3. Were either of your testicles undescended at birth? If yes, did you have surgery for this? 4. Have you had a traumatic injury to your penis or testicles? 5. Have you had a vasectomy? If yes, at what age? 6. Did you have it reversed? 7. Have you had a Prostate exam? Medical History/Family History Do you or any of your relatives have a history of the following? You Relative (relation to you) Anemia Bleeding tendency Cancer Colitis/Bowel trouble Depression! 1
2 Diabetes Glaucoma Heart Disease High Blood Pressure Kidney Disease Liver disease/hepatitis Lung Disease/Asthma Migraine Headaches Osteoporosis Psychiatric disorder Seizures/Epilepsy Thyroid Disease Stroke Ulcers Vein trouble/blood clots Other: Have you had any previous fractures? Any other serious injuries? Have you had any blood transfusions? Surgical history: Please list any surgeries not mentioned previously in this questionnaire: Surgical procedure Date _ Medications List medications or supplements you are currently taking: List any drug allergies:! 2
3 Are you allergic to latex: Bladder Symptoms 1. Have you ever filled out a bladder diary? 2. Do you have frequent urinary tract infections? 3. Do you lose urine when you cough/sneeze/laugh? 4. Do you lose urine during physical activity like running, jumping, lifting? 5. If you lose urine, how much do you leak? circle one: small, medium, large 6. Do you ever have strong, uncontrolled urges to urinate? If so, how many times per day 7. Do you ever lose urine because you cannot make it to the bathroom in time? 8. How many times do you urinate (void) throughout the day? 9. How many times do you void at night? 10. Does your bladder wake you up at night? 11. How large are your voids? circle one: small, medium, or large 12. Do you strain to urinate or empty your bladder? 13. Do you have difficulty starting a stream of urine? 14. Do you have a slow or weak flow? 15. Do you have splitting of the stream or dribbling? 16. Do you have pain or burning with urination? 17. Do you have blood in your urine? 18. Do you wear a pad for leakage? If so, how many times do you change the pad daily?! 3
4 19. How much fluid do you drink per day? 20. Do you drink caffeinated beverages regularly? 21. Do you drink alcohol regularly? Bowel Symptoms 1. How often do your move your bowels per day? week? 2. How often do you move your bowels at night? 3. Do you have constipation? 4. Do you strain/push out with bowel movements? 5. Do you have pain with bowel movements? 6. Do you have blood in your stools? 7. Do you often have diarrhea? 8. Do you leak and stain your underwear with feces? 9. Can you tell the difference between a bowel movement and passing gas? 10. Most common stool consistency? circle one: liquid, soft, firm, pellets, or other Pain Symptoms 1. Do you have pain with prolonged sitting? 2. Do you have pain with prolonged standing? 3. Do you have pain wearing tight clothing? 4. Do you have pain in the area between the rectum and penis? 5. Do you have pain in the genital area? 6. Do you experience abdominal pain?! 4
5 7. Do you have a history of back pain? 8. Do you have head/neck pain? 9. Do you clench your teeth or have jaw pain? 10. Do you have a history of headaches/migraines? 11. List any other areas of pain Please circle the level/number of pain you experience on a daily basis: [ [ [ [ [ [ [ [ [ [ ] No Moderate Worst Pain Pain Possible Pain Sexual History 1. Are you currently sexually active? 2. Do you have a desire to be sexually active? 3. Is sexual intercourse satisfactory to you? 4. What is your sexual preference? Circle one: Male, Female, Both 5. Do you have pain with sexual intercourse? If yes, describe the pain felt during sexual intercourse: burning, throbbing, stabbing, other 6. Are you able to achieve an erection easily? 7. Are you able to maintain an erection through completion of intercourse? 8. Do you have pain with an erection? 9. Do you have difficulty with ejaculation/orgasm?! 5
6 10. Do you ever lose urine during sexual intercourse? 11. Do you ever have bowel incontinence during sexual intercourse? 12. Do you have a history of physical, mental or sexual abuse? 13. Do you have a history of sexually transmitted diseases? If yes, please describe Lifestyle 1. Do you have a balanced diet? 2. Are there foods in your diet that aggravate your symptoms? 3. What is your occupation? 4. Do you spend long hours driving each day? 5. Do you stand or sit for long periods each day? 6. Have you ever fallen on/broken your tailbone? 7. Do you exercise? If so, how many times per week 8. Do you smoke? If yes, how many packs per day 9. Do you use recreational drugs? 10. Do your symptoms impact your social life? 11. Do your symptoms make you sad or depressed? 12. Do your symptoms interfere with family or household responsibilities? Sleeping patterns: 1. How many hours of sleep do you get nightly? 2. Do you wake up after a night s sleep feeling rested?! 6
7 3. How many hours of sleep do you need to feel rested? 4. Do you have difficulty falling asleep? 5. Do you drink caffeine or alcohol within three hours before bedtime? 6. Do you have night sweats? 7. Are you a restless sleeper? 8. Do you wake up in the morning with headaches? 9. What is your usual sleep position? 10. Do you often remember dreaming? 11. Does your partner keep you awake by their sleeping habits? 12. Do you snore? 13. Do you have a hard time breathing when you sleep? List any additional comments or concerns that were not addressed in the questionnaire: Thank you for your time, please contact Kamin Physical Therapy at (847) with any further questions or concerns.! 7
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