Social/Lifestyle Tobacco: yes no If yes, how much #PPD # years Year of discontinuation Alcohol: yes no If yes, how many beverages Recreational Drugs: yes no If yes, agents/usage Marital Status: single married widowed divorced # children Occupation:

ADVANCED UROLOGY ASSOCIATES 1541 Riverboat Center Drive

Joliet, IL 60431 Phone: (815) 409-4930 Fax: (815) 741-3263

www.AdvUro.com

Name Date Date of Birth Age Primary Care Physician Referral Source Preferred Pharmacy/Location

Allergies/Reactions Name Response Contrast/Iodine Dye: Yes No

1) 2) 3) 4)

Non Prescription Medications and Herbal Supplements Name Dosage Usage

1)

2)

3)

4)

Medication Dosage Usage 1) 2) 3) 4)

Medication Dosage Usage 5) 6) 7) 8)

Page 1

Cardiac: myocardial infarction, angina, CHF, arrhythmia, mitral valve prolapsed, hypercholesterolemia Stress test EKG Respiratory: asthma, bronchitis, COPD Neurological: headache, CVA, seizures Renal: chronic renal disease, acute renal disease Vascular: hypertension, peripheral vascular disease Musculoskeletal: arthritis, chronic back pain Gastrointestinal: ulcer disease, gastro-esophageal reflux Blood Disorders: anemia, hepatitis, blood clotting disorders, HIV Mental Health: depression, anxiety, dementia Endocrine: diabetes, hypothyroid Cancer: Other: Assistive Devices: glasses, contact lenses, dentures, partials, hearing aids

Yes No

Surgical History Procedures Year 1) 2) 3) 4) 5) 6) 7) 8)

Prior Urological History Diagnosis Year Resolved Ongoing 1) 2) 3)

Family Medical/Urological History Diagnosis Relationship 1) 2) 3)

Medical History

Social/Lifestyle Tobacco: yes no If yes, how much #PPD # years Year of discontinuation Alcohol: yes no If yes, how many beverages Recreational Drugs: yes no If yes, agents/usage Marital Status: single married widowed divorced # children Occupation:

ADVANCED UROLOGY ASSOCIATES 1541 Riverboat Center Drive

Joliet, IL 60431 Phone: (815) 409-4930 Fax: (815) 741-3263

www.AdvUro.com

Name Date Date of Birth Age Primary Care Physician Referral Source Preferred Pharmacy/Location

Allergies/Reactions Name Response Contrast/Iodine Dye: Yes No

1) 2) 3) 4)

Non Prescription Medications and Herbal Supplements Name Dosage Usage

1)

2)

3)

4)

Medication Dosage Usage 1) 2) 3) 4)

Medication Dosage Usage 5) 6) 7) 8)

Page 1

Cardiac: myocardial infarction, angina, CHF, arrhythmia, mitral valve prolapsed, hypercholesterolemia Stress test EKG Respiratory: asthma, bronchitis, COPD Neurological: headache, CVA, seizures Renal: chronic renal disease, acute renal disease Vascular: hypertension, peripheral vascular disease Musculoskeletal: arthritis, chronic back pain Gastrointestinal: ulcer disease, gastro-esophageal reflux Blood Disorders: anemia, hepatitis, blood clotting disorders, HIV Mental Health: depression, anxiety, dementia Endocrine: diabetes, hypothyroid Cancer: Other: Assistive Devices: glasses, contact lenses, dentures, partials, hearing aids

Yes No

Surgical History Procedures Year 1) 2) 3) 4) 5) 6) 7) 8)

Prior Urological History Diagnosis Year Resolved Ongoing 1) 2) 3)

Family Medical/Urological History Diagnosis Relationship 1) 2) 3)

Medical History

Please fill out back of document

1541 Riverboat Center Drive, Joliet, IL 60431PH: (815) 409-4930 | FAX: (815) 409-4940 | www.AdvUro.com

Social/Lifestyle Tobacco: yes no If yes, how much #PPD # years Year of discontinuation Alcohol: yes no If yes, how many beverages Recreational Drugs: yes no If yes, agents/usage Marital Status: single married widowed divorced # children Occupation:

ADVANCED UROLOGY ASSOCIATES 1541 Riverboat Center Drive

Joliet, IL 60431 Phone: (815) 409-4930 Fax: (815) 741-3263

www.AdvUro.com

Name Date Date of Birth Age Primary Care Physician Referral Source Preferred Pharmacy/Location

Allergies/Reactions Name Response Contrast/Iodine Dye: Yes No

1) 2) 3) 4)

Non Prescription Medications and Herbal Supplements Name Dosage Usage

1)

2)

3)

4)

Medication Dosage Usage 1) 2) 3) 4)

Medication Dosage Usage 5) 6) 7) 8)

Page 1

Cardiac: myocardial infarction, angina, CHF, arrhythmia, mitral valve prolapsed, hypercholesterolemia Stress test EKG Respiratory: asthma, bronchitis, COPD Neurological: headache, CVA, seizures Renal: chronic renal disease, acute renal disease Vascular: hypertension, peripheral vascular disease Musculoskeletal: arthritis, chronic back pain Gastrointestinal: ulcer disease, gastro-esophageal reflux Blood Disorders: anemia, hepatitis, blood clotting disorders, HIV Mental Health: depression, anxiety, dementia Endocrine: diabetes, hypothyroid Cancer: Other: Assistive Devices: glasses, contact lenses, dentures, partials, hearing aids

Yes No

Surgical History Procedures Year 1) 2) 3) 4) 5) 6) 7) 8)

Prior Urological History Diagnosis Year Resolved Ongoing 1) 2) 3)

Family Medical/Urological History Diagnosis Relationship 1) 2) 3)

Medical History

Advanced Urology Associates 1541 Riverboat Center Drive Joliet, IL 60431 phone: (815) 741-3825 fax: (815) 741-3263 Page 2 REVIEW OF SYSTEMS Patient Name __________________________________ Date _________________

Constitutional Symptoms Cardiovascular Pulmonary Gastrointestinal

Weight Change Y N Chest Pain Y N Shortness of Breath Y N Abdominal Pain Y N

Fever Y N Irregular Heartbeat Y N Frequent Cough Y N Nausea/Vomiting Y N

Chills Y N Wheezing Y N Constipation/Diarrhea Y N

Musculoskeletal Neurological Psychological Integumentary

Muscle Weakness Y N Dizziness Y N Depression Y N Skin Rash Y N

Joint Pain Y N Headache Y N Anxiety Y N Bruising Y N

Back Pain Y N Numbness/Tingling Y N Stress Y N

Hemotologic/Lymphatic Sexual Male Sexual Female

Blood clotting problems Y N Erectile quality changes Y N NA Pelvic pain Y N NA

Swollen glands Y N Libido change Y N NA Pelvic discharge Y N NA

Vital Signs: BP (sitting) ________/_____ BP (supine) _________/______ T ____________ P ____________ R ___________ WT ___________ HT ___________ Post Void Residual: Catheter __________ Scan ___________ Volume ___________ History of Present Illness Chief Complaint: ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ Physician: ______________________________________________________________________________________________________________________________________

Genitourinary Symptomatic Asymptomatic

Nocturia

Frequency

Urgency

Hesitancy

Dysuria

Hematuria

Post Void Empty

Force of Stream

Urinary Incontinence: Yes _____ No ______ Onset: _______________________________________________________ Episodes/Day: ________________________________________________ Protection: ___________________________________________________ Stress Incontinence: ____________________________________________ Urge Incontinence: _____________________________________________ Non-Stress/Non-Urge Incontinence: _______________________________ Nocturnal Enuresis: ____________________________________________ Prior Treatments: ______________________________________________

Advanced Urology Associates 1541 Riverboat Center Drive Joliet, IL 60431 phone: (815) 741-3825 fax: (815) 741-3263 Page 2 REVIEW OF SYSTEMS Patient Name __________________________________ Date _________________

Constitutional Symptoms Cardiovascular Pulmonary Gastrointestinal

Weight Change Y N Chest Pain Y N Shortness of Breath Y N Abdominal Pain Y N

Fever Y N Irregular Heartbeat Y N Frequent Cough Y N Nausea/Vomiting Y N

Chills Y N Wheezing Y N Constipation/Diarrhea Y N

Musculoskeletal Neurological Psychological Integumentary

Muscle Weakness Y N Dizziness Y N Depression Y N Skin Rash Y N

Joint Pain Y N Headache Y N Anxiety Y N Bruising Y N

Back Pain Y N Numbness/Tingling Y N Stress Y N

Hemotologic/Lymphatic Sexual Male Sexual Female

Blood clotting problems Y N Erectile quality changes Y N NA Pelvic pain Y N NA

Swollen glands Y N Libido change Y N NA Pelvic discharge Y N NA

Vital Signs: BP (sitting) ________/_____ BP (supine) _________/______ T ____________ P ____________ R ___________ WT ___________ HT ___________ Post Void Residual: Catheter __________ Scan ___________ Volume ___________ History of Present Illness Chief Complaint: ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ Physician: ______________________________________________________________________________________________________________________________________

Genitourinary Symptomatic Asymptomatic

Nocturia

Frequency

Urgency

Hesitancy

Dysuria

Hematuria

Post Void Empty

Force of Stream

Urinary Incontinence: Yes _____ No ______ Onset: _______________________________________________________ Episodes/Day: ________________________________________________ Protection: ___________________________________________________ Stress Incontinence: ____________________________________________ Urge Incontinence: _____________________________________________ Non-Stress/Non-Urge Incontinence: _______________________________ Nocturnal Enuresis: ____________________________________________ Prior Treatments: ______________________________________________

Advanced Urology Associates 1541 Riverboat Center Drive Joliet, IL 60431 phone: (815) 741-3825 fax: (815) 741-3263 Page 2 REVIEW OF SYSTEMS Patient Name __________________________________ Date _________________

Constitutional Symptoms Cardiovascular Pulmonary Gastrointestinal

Weight Change Y N Chest Pain Y N Shortness of Breath Y N Abdominal Pain Y N

Fever Y N Irregular Heartbeat Y N Frequent Cough Y N Nausea/Vomiting Y N

Chills Y N Wheezing Y N Constipation/Diarrhea Y N

Musculoskeletal Neurological Psychological Integumentary

Muscle Weakness Y N Dizziness Y N Depression Y N Skin Rash Y N

Joint Pain Y N Headache Y N Anxiety Y N Bruising Y N

Back Pain Y N Numbness/Tingling Y N Stress Y N

Hemotologic/Lymphatic Sexual Male Sexual Female

Blood clotting problems Y N Erectile quality changes Y N NA Pelvic pain Y N NA

Swollen glands Y N Libido change Y N NA Pelvic discharge Y N NA

Vital Signs: BP (sitting) ________/_____ BP (supine) _________/______ T ____________ P ____________ R ___________ WT ___________ HT ___________ Post Void Residual: Catheter __________ Scan ___________ Volume ___________ History of Present Illness Chief Complaint: ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ Physician: ______________________________________________________________________________________________________________________________________

Genitourinary Symptomatic Asymptomatic

Nocturia

Frequency

Urgency

Hesitancy

Dysuria

Hematuria

Post Void Empty

Force of Stream

Urinary Incontinence: Yes _____ No ______ Onset: _______________________________________________________ Episodes/Day: ________________________________________________ Protection: ___________________________________________________ Stress Incontinence: ____________________________________________ Urge Incontinence: _____________________________________________ Non-Stress/Non-Urge Incontinence: _______________________________ Nocturnal Enuresis: ____________________________________________ Prior Treatments: ______________________________________________

How would you feel if you had to live with your current urological problem the way it is now, no better, no worse, for the rest of your life?(Please circle the number that best reflects your feelings about the current problem we seeing you for today.)

Delighted0

Pleased1

Mostly Satisfied2

Mixed3

Mostly Dissatisfied4

Unhappy5

Terrible5

Terrible6

(Please circle the number that best reflects your feelings about the current problem we’re seeing you for today.)

Advanced Urology Associates 1541 Riverboat Center Drive Joliet, IL 60431 phone: (815) 741-3825 fax: (815) 741-3263 Page 2 REVIEW OF SYSTEMS Patient Name __________________________________ Date _________________

Constitutional Symptoms Cardiovascular Pulmonary Gastrointestinal

Weight Change Y N Chest Pain Y N Shortness of Breath Y N Abdominal Pain Y N

Fever Y N Irregular Heartbeat Y N Frequent Cough Y N Nausea/Vomiting Y N

Chills Y N Wheezing Y N Constipation/Diarrhea Y N

Musculoskeletal Neurological Psychological Integumentary

Muscle Weakness Y N Dizziness Y N Depression Y N Skin Rash Y N

Joint Pain Y N Headache Y N Anxiety Y N Bruising Y N

Back Pain Y N Numbness/Tingling Y N Stress Y N

Hemotologic/Lymphatic Sexual Male Sexual Female

Blood clotting problems Y N Erectile quality changes Y N NA Pelvic pain Y N NA

Swollen glands Y N Libido change Y N NA Pelvic discharge Y N NA

Vital Signs: BP (sitting) ________/_____ BP (supine) _________/______ T ____________ P ____________ R ___________ WT ___________ HT ___________ Post Void Residual: Catheter __________ Scan ___________ Volume ___________ History of Present Illness Chief Complaint: ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ Physician: ______________________________________________________________________________________________________________________________________

Genitourinary Symptomatic Asymptomatic

Nocturia

Frequency

Urgency

Hesitancy

Dysuria

Hematuria

Post Void Empty

Force of Stream

Urinary Incontinence: Yes _____ No ______ Onset: _______________________________________________________ Episodes/Day: ________________________________________________ Protection: ___________________________________________________ Stress Incontinence: ____________________________________________ Urge Incontinence: _____________________________________________ Non-Stress/Non-Urge Incontinence: _______________________________ Nocturnal Enuresis: ____________________________________________ Prior Treatments: ______________________________________________

Advanced Urology Associates 1541 Riverboat Center Drive Joliet, IL 60431 phone: (815) 741-3825 fax: (815) 741-3263 Page 2 REVIEW OF SYSTEMS Patient Name __________________________________ Date _________________

Constitutional Symptoms Cardiovascular Pulmonary Gastrointestinal

Weight Change Y N Chest Pain Y N Shortness of Breath Y N Abdominal Pain Y N

Fever Y N Irregular Heartbeat Y N Frequent Cough Y N Nausea/Vomiting Y N

Chills Y N Wheezing Y N Constipation/Diarrhea Y N

Musculoskeletal Neurological Psychological Integumentary

Muscle Weakness Y N Dizziness Y N Depression Y N Skin Rash Y N

Joint Pain Y N Headache Y N Anxiety Y N Bruising Y N

Back Pain Y N Numbness/Tingling Y N Stress Y N

Hemotologic/Lymphatic Sexual Male Sexual Female

Blood clotting problems Y N Erectile quality changes Y N NA Pelvic pain Y N NA

Swollen glands Y N Libido change Y N NA Pelvic discharge Y N NA

Vital Signs: BP (sitting) ________/_____ BP (supine) _________/______ T ____________ P ____________ R ___________ WT ___________ HT ___________ Post Void Residual: Catheter __________ Scan ___________ Volume ___________ History of Present Illness Chief Complaint: ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ Physician: ______________________________________________________________________________________________________________________________________

Genitourinary Symptomatic Asymptomatic

Nocturia

Frequency

Urgency

Hesitancy

Dysuria

Hematuria

Post Void Empty

Force of Stream

Urinary Incontinence: Yes _____ No ______ Onset: _______________________________________________________ Episodes/Day: ________________________________________________ Protection: ___________________________________________________ Stress Incontinence: ____________________________________________ Urge Incontinence: _____________________________________________ Non-Stress/Non-Urge Incontinence: _______________________________ Nocturnal Enuresis: ____________________________________________ Prior Treatments: ______________________________________________

Advanced Urology Associates 1541 Riverboat Center Drive Joliet, IL 60431 phone: (815) 741-3825 fax: (815) 741-3263 Page 2 REVIEW OF SYSTEMS Patient Name __________________________________ Date _________________

Constitutional Symptoms Cardiovascular Pulmonary Gastrointestinal

Weight Change Y N Chest Pain Y N Shortness of Breath Y N Abdominal Pain Y N

Fever Y N Irregular Heartbeat Y N Frequent Cough Y N Nausea/Vomiting Y N

Chills Y N Wheezing Y N Constipation/Diarrhea Y N

Musculoskeletal Neurological Psychological Integumentary

Muscle Weakness Y N Dizziness Y N Depression Y N Skin Rash Y N

Joint Pain Y N Headache Y N Anxiety Y N Bruising Y N

Back Pain Y N Numbness/Tingling Y N Stress Y N

Hemotologic/Lymphatic Sexual Male Sexual Female

Blood clotting problems Y N Erectile quality changes Y N NA Pelvic pain Y N NA

Swollen glands Y N Libido change Y N NA Pelvic discharge Y N NA

Vital Signs: BP (sitting) ________/_____ BP (supine) _________/______ T ____________ P ____________ R ___________ WT ___________ HT ___________ Post Void Residual: Catheter __________ Scan ___________ Volume ___________ History of Present Illness Chief Complaint: ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ Physician: ______________________________________________________________________________________________________________________________________

Genitourinary Symptomatic Asymptomatic

Nocturia

Frequency

Urgency

Hesitancy

Dysuria

Hematuria

Post Void Empty

Force of Stream

Urinary Incontinence: Yes _____ No ______ Onset: _______________________________________________________ Episodes/Day: ________________________________________________ Protection: ___________________________________________________ Stress Incontinence: ____________________________________________ Urge Incontinence: _____________________________________________ Non-Stress/Non-Urge Incontinence: _______________________________ Nocturnal Enuresis: ____________________________________________ Prior Treatments: ______________________________________________

How would you feel if you had to live with your current urological problem the way it is now, no better, no worse, for the rest of your life?(Please circle the number that best reflects your feelings about the current problem we seeing you for today.)

Delighted0

Pleased1

Mostly Satisfied2

Mixed3

Mostly Dissatisfied4

Unhappy5

Terrible5

Advanced Urology Associates | 1541 Riverboat Center Drive, Joliet, IL 60431 | PH: (815) 409-4930 | FAX: (815) 409-4940 | www.AdvUro.com

Social/Lifestyle Tobacco: yes no If yes, how much #PPD # years Year of discontinuation Alcohol: yes no If yes, how many beverages Recreational Drugs: yes no If yes, agents/usage Marital Status: single married widowed divorced # children Occupation:

ADVANCED UROLOGY ASSOCIATES 1541 Riverboat Center Drive

Joliet, IL 60431 Phone: (815) 409-4930 Fax: (815) 741-3263

www.AdvUro.com

Name Date Date of Birth Age Primary Care Physician Referral Source Preferred Pharmacy/Location

Allergies/Reactions Name Response Contrast/Iodine Dye: Yes No

1) 2) 3) 4)

Non Prescription Medications and Herbal Supplements Name Dosage Usage

1)

2)

3)

4)

Medication Dosage Usage 1) 2) 3) 4)

Medication Dosage Usage 5) 6) 7) 8)

Page 1

Cardiac: myocardial infarction, angina, CHF, arrhythmia, mitral valve prolapsed, hypercholesterolemia Stress test EKG Respiratory: asthma, bronchitis, COPD Neurological: headache, CVA, seizures Renal: chronic renal disease, acute renal disease Vascular: hypertension, peripheral vascular disease Musculoskeletal: arthritis, chronic back pain Gastrointestinal: ulcer disease, gastro-esophageal reflux Blood Disorders: anemia, hepatitis, blood clotting disorders, HIV Mental Health: depression, anxiety, dementia Endocrine: diabetes, hypothyroid Cancer: Other: Assistive Devices: glasses, contact lenses, dentures, partials, hearing aids

Yes No

Surgical History Procedures Year 1) 2) 3) 4) 5) 6) 7) 8)

Prior Urological History Diagnosis Year Resolved Ongoing 1) 2) 3)

Family Medical/Urological History Diagnosis Relationship 1) 2) 3)

Medical History

Advanced Urology Associates 1541 Riverboat Center Drive Joliet, IL 60431 phone: (815) 741-3825 fax: (815) 741-3263 Page 2 REVIEW OF SYSTEMS Patient Name __________________________________ Date _________________

Constitutional Symptoms Cardiovascular Pulmonary Gastrointestinal

Weight Change Y N Chest Pain Y N Shortness of Breath Y N Abdominal Pain Y N

Fever Y N Irregular Heartbeat Y N Frequent Cough Y N Nausea/Vomiting Y N

Chills Y N Wheezing Y N Constipation/Diarrhea Y N

Musculoskeletal Neurological Psychological Integumentary

Muscle Weakness Y N Dizziness Y N Depression Y N Skin Rash Y N

Joint Pain Y N Headache Y N Anxiety Y N Bruising Y N

Back Pain Y N Numbness/Tingling Y N Stress Y N

Hemotologic/Lymphatic Sexual Male Sexual Female

Blood clotting problems Y N Erectile quality changes Y N NA Pelvic pain Y N NA

Swollen glands Y N Libido change Y N NA Pelvic discharge Y N NA

Vital Signs: BP (sitting) ________/_____ BP (supine) _________/______ T ____________ P ____________ R ___________ WT ___________ HT ___________ Post Void Residual: Catheter __________ Scan ___________ Volume ___________ History of Present Illness Chief Complaint: ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ Physician: ______________________________________________________________________________________________________________________________________

Genitourinary Symptomatic Asymptomatic

Nocturia

Frequency

Urgency

Hesitancy

Dysuria

Hematuria

Post Void Empty

Force of Stream

Urinary Incontinence: Yes _____ No ______ Onset: _______________________________________________________ Episodes/Day: ________________________________________________ Protection: ___________________________________________________ Stress Incontinence: ____________________________________________ Urge Incontinence: _____________________________________________ Non-Stress/Non-Urge Incontinence: _______________________________ Nocturnal Enuresis: ____________________________________________ Prior Treatments: ______________________________________________

Advanced Urology Associates 1541 Riverboat Center Drive Joliet, IL 60431 phone: (815) 741-3825 fax: (815) 741-3263 Page 2 REVIEW OF SYSTEMS Patient Name __________________________________ Date _________________

Constitutional Symptoms Cardiovascular Pulmonary Gastrointestinal

Weight Change Y N Chest Pain Y N Shortness of Breath Y N Abdominal Pain Y N

Fever Y N Irregular Heartbeat Y N Frequent Cough Y N Nausea/Vomiting Y N

Chills Y N Wheezing Y N Constipation/Diarrhea Y N

Musculoskeletal Neurological Psychological Integumentary

Muscle Weakness Y N Dizziness Y N Depression Y N Skin Rash Y N

Joint Pain Y N Headache Y N Anxiety Y N Bruising Y N

Back Pain Y N Numbness/Tingling Y N Stress Y N

Hemotologic/Lymphatic Sexual Male Sexual Female

Blood clotting problems Y N Erectile quality changes Y N NA Pelvic pain Y N NA

Swollen glands Y N Libido change Y N NA Pelvic discharge Y N NA

Vital Signs: BP (sitting) ________/_____ BP (supine) _________/______ T ____________ P ____________ R ___________ WT ___________ HT ___________ Post Void Residual: Catheter __________ Scan ___________ Volume ___________ History of Present Illness Chief Complaint: ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ Physician: ______________________________________________________________________________________________________________________________________

Genitourinary Symptomatic Asymptomatic

Nocturia

Frequency

Urgency

Hesitancy

Dysuria

Hematuria

Post Void Empty

Force of Stream

Urinary Incontinence: Yes _____ No ______ Onset: _______________________________________________________ Episodes/Day: ________________________________________________ Protection: ___________________________________________________ Stress Incontinence: ____________________________________________ Urge Incontinence: _____________________________________________ Non-Stress/Non-Urge Incontinence: _______________________________ Nocturnal Enuresis: ____________________________________________ Prior Treatments: ______________________________________________

Advanced Urology Associates 1541 Riverboat Center Drive Joliet, IL 60431 phone: (815) 741-3825 fax: (815) 741-3263 Page 2 REVIEW OF SYSTEMS Patient Name __________________________________ Date _________________

Constitutional Symptoms Cardiovascular Pulmonary Gastrointestinal

Weight Change Y N Chest Pain Y N Shortness of Breath Y N Abdominal Pain Y N

Fever Y N Irregular Heartbeat Y N Frequent Cough Y N Nausea/Vomiting Y N

Chills Y N Wheezing Y N Constipation/Diarrhea Y N

Musculoskeletal Neurological Psychological Integumentary

Muscle Weakness Y N Dizziness Y N Depression Y N Skin Rash Y N

Joint Pain Y N Headache Y N Anxiety Y N Bruising Y N

Back Pain Y N Numbness/Tingling Y N Stress Y N

Hemotologic/Lymphatic Sexual Male Sexual Female

Blood clotting problems Y N Erectile quality changes Y N NA Pelvic pain Y N NA

Swollen glands Y N Libido change Y N NA Pelvic discharge Y N NA

Vital Signs: BP (sitting) ________/_____ BP (supine) _________/______ T ____________ P ____________ R ___________ WT ___________ HT ___________ Post Void Residual: Catheter __________ Scan ___________ Volume ___________ History of Present Illness Chief Complaint: ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ Physician: ______________________________________________________________________________________________________________________________________

Genitourinary Symptomatic Asymptomatic

Nocturia

Frequency

Urgency

Hesitancy

Dysuria

Hematuria

Post Void Empty

Force of Stream

Urinary Incontinence: Yes _____ No ______ Onset: _______________________________________________________ Episodes/Day: ________________________________________________ Protection: ___________________________________________________ Stress Incontinence: ____________________________________________ Urge Incontinence: _____________________________________________ Non-Stress/Non-Urge Incontinence: _______________________________ Nocturnal Enuresis: ____________________________________________ Prior Treatments: ______________________________________________

How would you feel if you had to live with your current urological problem the way it is now, no better, no worse, for the rest of your life?(Please circle the number that best reflects your feelings about the current problem we seeing you for today.)

Delighted0

Pleased1

Mostly Satisfied2

Mixed3

Mostly Dissatisfied4

Unhappy5

Terrible5

Advanced Urology Associates 1541 Riverboat Center Drive Joliet, IL 60431 phone: (815) 741-3825 fax: (815) 741-3263 Page 2 REVIEW OF SYSTEMS Patient Name __________________________________ Date _________________

Constitutional Symptoms Cardiovascular Pulmonary Gastrointestinal

Weight Change Y N Chest Pain Y N Shortness of Breath Y N Abdominal Pain Y N

Fever Y N Irregular Heartbeat Y N Frequent Cough Y N Nausea/Vomiting Y N

Chills Y N Wheezing Y N Constipation/Diarrhea Y N

Musculoskeletal Neurological Psychological Integumentary

Muscle Weakness Y N Dizziness Y N Depression Y N Skin Rash Y N

Joint Pain Y N Headache Y N Anxiety Y N Bruising Y N

Back Pain Y N Numbness/Tingling Y N Stress Y N

Hemotologic/Lymphatic Sexual Male Sexual Female

Blood clotting problems Y N Erectile quality changes Y N NA Pelvic pain Y N NA

Swollen glands Y N Libido change Y N NA Pelvic discharge Y N NA

Vital Signs: BP (sitting) ________/_____ BP (supine) _________/______ T ____________ P ____________ R ___________ WT ___________ HT ___________ Post Void Residual: Catheter __________ Scan ___________ Volume ___________ History of Present Illness Chief Complaint: ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ Physician: ______________________________________________________________________________________________________________________________________

Genitourinary Symptomatic Asymptomatic

Nocturia

Frequency

Urgency

Hesitancy

Dysuria

Hematuria

Post Void Empty

Force of Stream

Urinary Incontinence: Yes _____ No ______ Onset: _______________________________________________________ Episodes/Day: ________________________________________________ Protection: ___________________________________________________ Stress Incontinence: ____________________________________________ Urge Incontinence: _____________________________________________ Non-Stress/Non-Urge Incontinence: _______________________________ Nocturnal Enuresis: ____________________________________________ Prior Treatments: ______________________________________________

Advanced Urology Associates 1541 Riverboat Center Drive Joliet, IL 60431 phone: (815) 741-3825 fax: (815) 741-3263 Page 2 REVIEW OF SYSTEMS Patient Name __________________________________ Date _________________

Constitutional Symptoms Cardiovascular Pulmonary Gastrointestinal

Weight Change Y N Chest Pain Y N Shortness of Breath Y N Abdominal Pain Y N

Fever Y N Irregular Heartbeat Y N Frequent Cough Y N Nausea/Vomiting Y N

Chills Y N Wheezing Y N Constipation/Diarrhea Y N

Musculoskeletal Neurological Psychological Integumentary

Muscle Weakness Y N Dizziness Y N Depression Y N Skin Rash Y N

Joint Pain Y N Headache Y N Anxiety Y N Bruising Y N

Back Pain Y N Numbness/Tingling Y N Stress Y N

Hemotologic/Lymphatic Sexual Male Sexual Female

Blood clotting problems Y N Erectile quality changes Y N NA Pelvic pain Y N NA

Swollen glands Y N Libido change Y N NA Pelvic discharge Y N NA

Vital Signs: BP (sitting) ________/_____ BP (supine) _________/______ T ____________ P ____________ R ___________ WT ___________ HT ___________ Post Void Residual: Catheter __________ Scan ___________ Volume ___________ History of Present Illness Chief Complaint: ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ Physician: ______________________________________________________________________________________________________________________________________

Genitourinary Symptomatic Asymptomatic

Nocturia

Frequency

Urgency

Hesitancy

Dysuria

Hematuria

Post Void Empty

Force of Stream

Urinary Incontinence: Yes _____ No ______ Onset: _______________________________________________________ Episodes/Day: ________________________________________________ Protection: ___________________________________________________ Stress Incontinence: ____________________________________________ Urge Incontinence: _____________________________________________ Non-Stress/Non-Urge Incontinence: _______________________________ Nocturnal Enuresis: ____________________________________________ Prior Treatments: ______________________________________________

Advanced Urology Associates 1541 Riverboat Center Drive Joliet, IL 60431 phone: (815) 741-3825 fax: (815) 741-3263 Page 2 REVIEW OF SYSTEMS Patient Name __________________________________ Date _________________

Constitutional Symptoms Cardiovascular Pulmonary Gastrointestinal

Weight Change Y N Chest Pain Y N Shortness of Breath Y N Abdominal Pain Y N

Fever Y N Irregular Heartbeat Y N Frequent Cough Y N Nausea/Vomiting Y N

Chills Y N Wheezing Y N Constipation/Diarrhea Y N

Musculoskeletal Neurological Psychological Integumentary

Muscle Weakness Y N Dizziness Y N Depression Y N Skin Rash Y N

Joint Pain Y N Headache Y N Anxiety Y N Bruising Y N

Back Pain Y N Numbness/Tingling Y N Stress Y N

Hemotologic/Lymphatic Sexual Male Sexual Female

Blood clotting problems Y N Erectile quality changes Y N NA Pelvic pain Y N NA

Swollen glands Y N Libido change Y N NA Pelvic discharge Y N NA

Vital Signs: BP (sitting) ________/_____ BP (supine) _________/______ T ____________ P ____________ R ___________ WT ___________ HT ___________ Post Void Residual: Catheter __________ Scan ___________ Volume ___________ History of Present Illness Chief Complaint: ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ Physician: ______________________________________________________________________________________________________________________________________

Genitourinary Symptomatic Asymptomatic

Nocturia

Frequency

Urgency

Hesitancy

Dysuria

Hematuria

Post Void Empty

Force of Stream

Urinary Incontinence: Yes _____ No ______ Onset: _______________________________________________________ Episodes/Day: ________________________________________________ Protection: ___________________________________________________ Stress Incontinence: ____________________________________________ Urge Incontinence: _____________________________________________ Non-Stress/Non-Urge Incontinence: _______________________________ Nocturnal Enuresis: ____________________________________________ Prior Treatments: ______________________________________________

How would you feel if you had to live with your current urological problem the way it is now, no better, no worse, for the rest of your life?(Please circle the number that best reflects your feelings about the current problem we seeing you for today.)

Delighted0

Pleased1

Mostly Satisfied2

Mixed3

Mostly Dissatisfied4

Unhappy5

Terrible5

Advanced Urology Associates 1541 Riverboat Center Drive Joliet, IL 60431 phone: (815) 741-3825 fax: (815) 741-3263 Page 2 REVIEW OF SYSTEMS Patient Name __________________________________ Date _________________

Constitutional Symptoms Cardiovascular Pulmonary Gastrointestinal

Weight Change Y N Chest Pain Y N Shortness of Breath Y N Abdominal Pain Y N

Fever Y N Irregular Heartbeat Y N Frequent Cough Y N Nausea/Vomiting Y N

Chills Y N Wheezing Y N Constipation/Diarrhea Y N

Musculoskeletal Neurological Psychological Integumentary

Muscle Weakness Y N Dizziness Y N Depression Y N Skin Rash Y N

Joint Pain Y N Headache Y N Anxiety Y N Bruising Y N

Back Pain Y N Numbness/Tingling Y N Stress Y N

Hemotologic/Lymphatic Sexual Male Sexual Female

Blood clotting problems Y N Erectile quality changes Y N NA Pelvic pain Y N NA

Swollen glands Y N Libido change Y N NA Pelvic discharge Y N NA

Vital Signs: BP (sitting) ________/_____ BP (supine) _________/______ T ____________ P ____________ R ___________ WT ___________ HT ___________ Post Void Residual: Catheter __________ Scan ___________ Volume ___________ History of Present Illness Chief Complaint: ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ Physician: ______________________________________________________________________________________________________________________________________

Genitourinary Symptomatic Asymptomatic

Nocturia

Frequency

Urgency

Hesitancy

Dysuria

Hematuria

Post Void Empty

Force of Stream

Urinary Incontinence: Yes _____ No ______ Onset: _______________________________________________________ Episodes/Day: ________________________________________________ Protection: ___________________________________________________ Stress Incontinence: ____________________________________________ Urge Incontinence: _____________________________________________ Non-Stress/Non-Urge Incontinence: _______________________________ Nocturnal Enuresis: ____________________________________________ Prior Treatments: ______________________________________________

Advanced Urology Associates 1541 Riverboat Center Drive Joliet, IL 60431 phone: (815) 741-3825 fax: (815) 741-3263 Page 2 REVIEW OF SYSTEMS Patient Name __________________________________ Date _________________

Constitutional Symptoms Cardiovascular Pulmonary Gastrointestinal

Weight Change Y N Chest Pain Y N Shortness of Breath Y N Abdominal Pain Y N

Fever Y N Irregular Heartbeat Y N Frequent Cough Y N Nausea/Vomiting Y N

Chills Y N Wheezing Y N Constipation/Diarrhea Y N

Musculoskeletal Neurological Psychological Integumentary

Muscle Weakness Y N Dizziness Y N Depression Y N Skin Rash Y N

Joint Pain Y N Headache Y N Anxiety Y N Bruising Y N

Back Pain Y N Numbness/Tingling Y N Stress Y N

Hemotologic/Lymphatic Sexual Male Sexual Female

Blood clotting problems Y N Erectile quality changes Y N NA Pelvic pain Y N NA

Swollen glands Y N Libido change Y N NA Pelvic discharge Y N NA

Vital Signs: BP (sitting) ________/_____ BP (supine) _________/______ T ____________ P ____________ R ___________ WT ___________ HT ___________ Post Void Residual: Catheter __________ Scan ___________ Volume ___________ History of Present Illness Chief Complaint: ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ Physician: ______________________________________________________________________________________________________________________________________

Genitourinary Symptomatic Asymptomatic

Nocturia

Frequency

Urgency

Hesitancy

Dysuria

Hematuria

Post Void Empty

Force of Stream

Urinary Incontinence: Yes _____ No ______ Onset: _______________________________________________________ Episodes/Day: ________________________________________________ Protection: ___________________________________________________ Stress Incontinence: ____________________________________________ Urge Incontinence: _____________________________________________ Non-Stress/Non-Urge Incontinence: _______________________________ Nocturnal Enuresis: ____________________________________________ Prior Treatments: ______________________________________________

Advanced Urology Associates 1541 Riverboat Center Drive Joliet, IL 60431 phone: (815) 741-3825 fax: (815) 741-3263 Page 2 REVIEW OF SYSTEMS Patient Name __________________________________ Date _________________

Constitutional Symptoms Cardiovascular Pulmonary Gastrointestinal

Weight Change Y N Chest Pain Y N Shortness of Breath Y N Abdominal Pain Y N

Fever Y N Irregular Heartbeat Y N Frequent Cough Y N Nausea/Vomiting Y N

Chills Y N Wheezing Y N Constipation/Diarrhea Y N

Musculoskeletal Neurological Psychological Integumentary

Muscle Weakness Y N Dizziness Y N Depression Y N Skin Rash Y N

Joint Pain Y N Headache Y N Anxiety Y N Bruising Y N

Back Pain Y N Numbness/Tingling Y N Stress Y N

Hemotologic/Lymphatic Sexual Male Sexual Female

Blood clotting problems Y N Erectile quality changes Y N NA Pelvic pain Y N NA

Swollen glands Y N Libido change Y N NA Pelvic discharge Y N NA

Vital Signs: BP (sitting) ________/_____ BP (supine) _________/______ T ____________ P ____________ R ___________ WT ___________ HT ___________ Post Void Residual: Catheter __________ Scan ___________ Volume ___________ History of Present Illness Chief Complaint: ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ Physician: ______________________________________________________________________________________________________________________________________

Genitourinary Symptomatic Asymptomatic

Nocturia

Frequency

Urgency

Hesitancy

Dysuria

Hematuria

Post Void Empty

Force of Stream

Urinary Incontinence: Yes _____ No ______ Onset: _______________________________________________________ Episodes/Day: ________________________________________________ Protection: ___________________________________________________ Stress Incontinence: ____________________________________________ Urge Incontinence: _____________________________________________ Non-Stress/Non-Urge Incontinence: _______________________________ Nocturnal Enuresis: ____________________________________________ Prior Treatments: ______________________________________________

How would you feel if you had to live with your current urological problem the way it is now, no better, no worse, for the rest of your life?(Please circle the number that best reflects your feelings about the current problem we seeing you for today.)

Delighted0

Pleased1

Mostly Satisfied2

Mixed3

Mostly Dissatisfied4

Unhappy5

Terrible5

Advanced Urology Associates 1541 Riverboat Center Drive Joliet, IL 60431 phone: (815) 741-3825 fax: (815) 741-3263 Page 2 REVIEW OF SYSTEMS Patient Name __________________________________ Date _________________

Constitutional Symptoms Cardiovascular Pulmonary Gastrointestinal

Weight Change Y N Chest Pain Y N Shortness of Breath Y N Abdominal Pain Y N

Fever Y N Irregular Heartbeat Y N Frequent Cough Y N Nausea/Vomiting Y N

Chills Y N Wheezing Y N Constipation/Diarrhea Y N

Musculoskeletal Neurological Psychological Integumentary

Muscle Weakness Y N Dizziness Y N Depression Y N Skin Rash Y N

Joint Pain Y N Headache Y N Anxiety Y N Bruising Y N

Back Pain Y N Numbness/Tingling Y N Stress Y N

Hemotologic/Lymphatic Sexual Male Sexual Female

Blood clotting problems Y N Erectile quality changes Y N NA Pelvic pain Y N NA

Swollen glands Y N Libido change Y N NA Pelvic discharge Y N NA

Vital Signs: BP (sitting) ________/_____ BP (supine) _________/______ T ____________ P ____________ R ___________ WT ___________ HT ___________ Post Void Residual: Catheter __________ Scan ___________ Volume ___________ History of Present Illness Chief Complaint: ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ Physician: ______________________________________________________________________________________________________________________________________

Genitourinary Symptomatic Asymptomatic

Nocturia

Frequency

Urgency

Hesitancy

Dysuria

Hematuria

Post Void Empty

Force of Stream

Urinary Incontinence: Yes _____ No ______ Onset: _______________________________________________________ Episodes/Day: ________________________________________________ Protection: ___________________________________________________ Stress Incontinence: ____________________________________________ Urge Incontinence: _____________________________________________ Non-Stress/Non-Urge Incontinence: _______________________________ Nocturnal Enuresis: ____________________________________________ Prior Treatments: ______________________________________________

Advanced Urology Associates 1541 Riverboat Center Drive Joliet, IL 60431 phone: (815) 741-3825 fax: (815) 741-3263 Page 2 REVIEW OF SYSTEMS Patient Name __________________________________ Date _________________

Constitutional Symptoms Cardiovascular Pulmonary Gastrointestinal

Weight Change Y N Chest Pain Y N Shortness of Breath Y N Abdominal Pain Y N

Fever Y N Irregular Heartbeat Y N Frequent Cough Y N Nausea/Vomiting Y N

Chills Y N Wheezing Y N Constipation/Diarrhea Y N

Musculoskeletal Neurological Psychological Integumentary

Muscle Weakness Y N Dizziness Y N Depression Y N Skin Rash Y N

Joint Pain Y N Headache Y N Anxiety Y N Bruising Y N

Back Pain Y N Numbness/Tingling Y N Stress Y N

Hemotologic/Lymphatic Sexual Male Sexual Female

Blood clotting problems Y N Erectile quality changes Y N NA Pelvic pain Y N NA

Swollen glands Y N Libido change Y N NA Pelvic discharge Y N NA

Vital Signs: BP (sitting) ________/_____ BP (supine) _________/______ T ____________ P ____________ R ___________ WT ___________ HT ___________ Post Void Residual: Catheter __________ Scan ___________ Volume ___________ History of Present Illness Chief Complaint: ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ Physician: ______________________________________________________________________________________________________________________________________

Genitourinary Symptomatic Asymptomatic

Nocturia

Frequency

Urgency

Hesitancy

Dysuria

Hematuria

Post Void Empty

Force of Stream

Urinary Incontinence: Yes _____ No ______ Onset: _______________________________________________________ Episodes/Day: ________________________________________________ Protection: ___________________________________________________ Stress Incontinence: ____________________________________________ Urge Incontinence: _____________________________________________ Non-Stress/Non-Urge Incontinence: _______________________________ Nocturnal Enuresis: ____________________________________________ Prior Treatments: ______________________________________________

Advanced Urology Associates 1541 Riverboat Center Drive Joliet, IL 60431 phone: (815) 741-3825 fax: (815) 741-3263 Page 2 REVIEW OF SYSTEMS Patient Name __________________________________ Date _________________

Constitutional Symptoms Cardiovascular Pulmonary Gastrointestinal

Weight Change Y N Chest Pain Y N Shortness of Breath Y N Abdominal Pain Y N

Fever Y N Irregular Heartbeat Y N Frequent Cough Y N Nausea/Vomiting Y N

Chills Y N Wheezing Y N Constipation/Diarrhea Y N

Musculoskeletal Neurological Psychological Integumentary

Muscle Weakness Y N Dizziness Y N Depression Y N Skin Rash Y N

Joint Pain Y N Headache Y N Anxiety Y N Bruising Y N

Back Pain Y N Numbness/Tingling Y N Stress Y N

Hemotologic/Lymphatic Sexual Male Sexual Female

Blood clotting problems Y N Erectile quality changes Y N NA Pelvic pain Y N NA

Swollen glands Y N Libido change Y N NA Pelvic discharge Y N NA

Vital Signs: BP (sitting) ________/_____ BP (supine) _________/______ T ____________ P ____________ R ___________ WT ___________ HT ___________ Post Void Residual: Catheter __________ Scan ___________ Volume ___________ History of Present Illness Chief Complaint: ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ Physician: ______________________________________________________________________________________________________________________________________

Genitourinary Symptomatic Asymptomatic

Nocturia

Frequency

Urgency

Hesitancy

Dysuria

Hematuria

Post Void Empty

Force of Stream

Urinary Incontinence: Yes _____ No ______ Onset: _______________________________________________________ Episodes/Day: ________________________________________________ Protection: ___________________________________________________ Stress Incontinence: ____________________________________________ Urge Incontinence: _____________________________________________ Non-Stress/Non-Urge Incontinence: _______________________________ Nocturnal Enuresis: ____________________________________________ Prior Treatments: ______________________________________________

How would you feel if you had to live with your current urological problem the way it is now, no better, no worse, for the rest of your life?(Please circle the number that best reflects your feelings about the current problem we seeing you for today.)

Delighted0

Pleased1

Mostly Satisfied2

Mixed3

Mostly Dissatisfied4

Unhappy5

Terrible5

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