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Patient Medical History and Review of Systems — Male
Please complete this form before your appointment. Review of systems means questions about symptoms you may have. Have your medication list and allergy information available. Enter information for one patient only. Answer what you know; you may leave optional questions blank or choose Not sure or Prefer to discuss. Please review your answers and select Submit history and ROS when finished. Completing this form does not confirm an appointment. Your care team will review them for your visit. This form is not monitored for emergencies. Call 911 for an emergency.
Encounter details
Patient full name
First Name
Middle Name
Last Name
Date of birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Upcoming appointment date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Best contact phone number
-
Country Code
-
Area Code
Phone Number
Email address
example@example.com
Specialty for this visit
Please Select
Urology
Gynecology
Interventional radiology / vascular care
Other or not sure
Main reason for your visit
Please Select
Urology: urinary symptoms
Urology: enlarged prostate
Urology: kidney stones
Urology: blood in urine
Urology: urinary infections
Urology: erectile or sexual health
Urology: testosterone concerns
Urology: vasectomy
Urology: second opinion
Gynecology: annual visit
Gynecology: abnormal bleeding
Gynecology: fibroids
Gynecology: pelvic pain
Gynecology: vaginal symptoms
Gynecology: menopause symptoms
Gynecology: contraception
Gynecology: abnormal Pap or HPV follow-up
Gynecology: bladder concerns
Interventional radiology / vascular care: prostate artery embolization
Interventional radiology / vascular care: fibroid embolization
Interventional radiology / vascular care: leg veins
Interventional radiology / vascular care: leg circulation or PAD
Other or not sure
Main concern and when it started
Current medications
Medication allergies
No known allergies
Yes
Not sure
Allergy or reaction details
Relevant medical conditions or major surgeries
Medical record number
Date completed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Practice/site
Office/location
Visit type
New patient
Follow-up
Other
Primary clinician
First Name
Middle Name
Last Name
Referring clinician
First Name
Middle Name
Last Name
Primary care clinician
First Name
Middle Name
Last Name
Preferred name
Pronouns
Gender identity
Relevant anatomy or hormone-therapy context
Preferred language
Please Select
English
Spanish
French
Chinese
Arabic
Other
Interpreter used
Yes
No
Not assessed
Interpreter name or ID
Who is completing this form? (patient or person helping)
First Name
Middle Name
Last Name
History source
Patient
Caregiver
Chart
Multiple
Other
Historian relationship
Anything you are unsure about or would like to discuss at your visit
Back
Next
History — patient reported or obtained by staff
Chief concern and HPI
Chief concern
Onset date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Duration
Location
Character / description
Severity
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Frequency / timing
Please Select
Constant
Intermittent
Daily
Weekly
Monthly
Occurs with activity
Occurs at rest
Other
Course since onset
Please Select
Improving
Worsening
Unchanged
Waxing and waning
Resolved and returned
Other
Radiation
Aggravating factors
Relieving factors
Associated symptoms
Fever
Nausea
Vomiting
Dizziness
Shortness of breath
Chest discomfort
Cough
Headache
Fatigue
Other
Functional impact
Please Select
No limitation
Mild limitation
Moderate limitation
Severe limitation
Unable to perform usual activities
Other
Prior episodes
Please Select
No
Yes, similar episode
Yes, different episode
Unsure
Other
Previous evaluation
Previous treatments
Treatment response
Please Select
Complete relief
Partial relief
No relief
Worsened
Not tried
Other
Patient goals / questions
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HPI summary
Past medical history
High blood pressure
Yes
No
Unknown
Coronary artery disease / heart attack
Yes
No
Unknown
Heart failure
Yes
No
Unknown
Heart rhythm disorder
Yes
No
Unknown
Stroke / TIA
Yes
No
Unknown
Blood clot / DVT / PE
Yes
No
Unknown
Bleeding disorder
Yes
No
Unknown
Diabetes
Yes
No
Unknown
Thyroid disease
Yes
No
Unknown
Asthma
Yes
No
Unknown
COPD
Yes
No
Unknown
Sleep apnea
Yes
No
Unknown
Kidney disease
Yes
No
Unknown
Kidney stones
Yes
No
Unknown
Recurrent urinary tract infection
Yes
No
Unknown
Liver disease
Yes
No
Unknown
Gastrointestinal disease
Yes
No
Unknown
Neurologic disorder
Yes
No
Unknown
Seizures
Yes
No
Unknown
Arthritis / musculoskeletal disease
Yes
No
Unknown
Cancer
Yes
No
Unknown
Depression
Yes
No
Unknown
Anxiety
Yes
No
Unknown
Other mental-health condition
Yes
No
Unknown
Infectious disease affecting care
Yes
No
Unknown
Other medical conditions
Medical history details and approximate dates
Cancer type / site and treatment
Hospitalizations
Significant infections
Implanted devices
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Anesthesia problems
Blood transfusion history
Yes
No
Unknown
Medications
Medication list status
Please Select
Medications entered
No current medications reported
Unknown
Not reconciled
Medication 1 name
Medication 1 strength/dose
Medication 1 route
Medication 1 frequency
Medication 1 indication
Medication 1 prescriber
Medication 2 name
Medication 2 strength/dose
Medication 2 route
Medication 2 frequency
Medication 2 indication
Medication 2 prescriber
Medication 3 name
Medication 3 strength/dose
Medication 3 route
Medication 3 frequency
Medication 3 indication
Medication 3 prescriber
Medication 4 name
Medication 4 strength/dose
Medication 4 route
Medication 4 frequency
Medication 4 indication
Medication 4 prescriber
Medication 5 name
Medication 5 strength/dose
Medication 5 route
Medication 5 frequency
Medication 5 indication
Medication 5 prescriber
Additional medications narrative
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Anticoagulant/antiplatelet medication details
Allergies
Allergy status
Please Select
Allergies entered
No known allergies reported
Unknown
Not reviewed
Allergy substance 1
Reaction 1
Severity 1
Please Select
Mild
Moderate
Severe
Unknown
Approximate reaction date 1
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Allergy substance 2
Reaction 2
Severity 2
Please Select
Mild
Moderate
Severe
Unknown
Approximate reaction date 2
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Allergy substance 3
Reaction 3
Severity 3
Please Select
Mild
Moderate
Severe
Unknown
Approximate reaction date 3
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Latex allergy
Please Select
Yes
No
Unknown
Contrast-agent reaction
Please Select
Yes
No
Unknown
Other allergy details
Allergy note
Facility or clinician 3
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Approximate date 4
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Facility or clinician 4
Complications 4
Procedures and surgeries
Prior anesthesia complications
None
Nausea or vomiting
Breathing problems
Allergic reaction
Delayed recovery
Other
Back
Next
Anesthesia complication details
Family history
Family history availability
Please Select
Known
Limited
Unknown
Adopted/unknown biologic history
Family history of prostate cancer
Yes
No
Unknown
Family history of breast cancer
Yes
No
Unknown
Family history of ovarian cancer
Yes
No
Unknown
Family history of colorectal cancer
Yes
No
Unknown
Family history of kidney or bladder cancer
Yes
No
Unknown
Family history of early cardiovascular disease
Yes
No
Unknown
Family history of diabetes
Yes
No
Unknown
Family history of known hereditary cancer syndrome
Yes
No
Unknown
Procedure name 1
Approximate date 1
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Facility or clinician 1
Complications 1
Procedure name 2
Approximate date 2
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Facility or clinician 2
Complications 2
Procedure name 3
Approximate date 3
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional family history
Complications 3
Procedure name 4
Additional procedures note
Maternal relatives with significant conditions
None known
Cancer
Heart disease
Diabetes
Stroke
Other
Paternal relatives with significant conditions
None known
Cancer
Heart disease
Diabetes
Stroke
Other
Relative / relationship 1
Condition 1
Age at diagnosis 1
Additional detail 1
Relative / relationship 2
Condition 2
Age at diagnosis 2
Additional detail 2
Relative / relationship 3
Condition 3
Age at diagnosis 3
Additional detail 3
Siblings with significant conditions
None known
Cancer
Heart disease
Diabetes
Stroke
Other
Children with significant conditions
None known
Cancer
Heart disease
Diabetes
Stroke
Other
Any family history of sudden unexplained death
Yes
No
Unknown
Back
Next
Any family history of clotting disorder
Yes
No
Unknown
Any family history of thyroid disease
Yes
No
Unknown
Any family history of autoimmune disease
Yes
No
Unknown
Any family history of neurologic disease
Yes
No
Unknown
Any family history of mental health condition
Yes
No
Unknown
Any family history of other major inherited condition
Yes
No
Unknown
Social and functional history
Tobacco status
Never
Former
Current
Unknown
Tobacco type
Please Select
Cigarettes
Cigars
Pipe
Smokeless tobacco
Other
Tobacco amount
Years used
Quit date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Vaping status
Never
Former
Current
Unknown
Alcohol frequency
Please Select
Never
Monthly or less
2-4 times a month
2-3 times a week
4 or more times a week
Prefer not to answer
Alcohol amount
Recreational substance use
Yes
No
Prefer to discuss
Unknown
Substance details
Occupation
Occupational exposures
Living situation
Please Select
Lives alone
Lives with spouse/partner
Lives with family
Lives with friends/roommates
Assisted living
Skilled nursing facility
Shelter/temporary housing
Other
Support system
Family
Friends
Partner/spouse
Community services
Faith/community group
Caregiver
Other
Activity / exercise
Dietary considerations
Sleep
Back
Next
Mobility limitations
Help with daily activities
Falls history
Home safety concerns
Yes
No
Prefer to discuss
Not assessed
Social barriers to care
Advance-directive status
Please Select
Has advance directive on file
Has advance directive, not on file
No advance directive
Unsure
Prefer not to answer
Healthcare decision-maker
Sexual and reproductive history
Back
Next
Sexually active
Yes
No
Prefer to discuss
Not assessed
Partner and anatomy considerations relevant to care
Female partner(s)
Male partner(s)
Partners of any gender
Vaginal sex
Anal sex
Oral sex
None of the above
Prefer to discuss
Other
Sexual health concerns
Pain with sex
Low desire
Erection concerns
Ejaculation concerns
Difficulty with arousal
Relationship concerns
Sexual trauma history
No concerns
Prefer to discuss
Other
History of sexually transmitted infection
None
Chlamydia
Gonorrhea
Syphilis
HIV
Hepatitis B
Hepatitis C
Herpes simplex
Human papillomavirus
Trichomonas
Other
Concerns about sexually transmitted infection testing
Recent exposure
Symptoms
Routine screening
Partner diagnosis
New partner
Testing not needed
Prefer to discuss
Other
Contraception or barrier use
Condoms
Internal condoms
Withdrawal
Hormonal contraception with partner
Long-acting reversible contraception with partner
None
Prefer to discuss
Other
Fertility goals
Please Select
Wants children
Does not want children
Unsure
Has children and no current desire for more
Prefer to discuss
Hormone medications details
Urinary history
Pain or burning with urination
Present
Absent
Unknown
Not assessed
Urinary frequency
Present
Absent
Unknown
Not assessed
Urinary urgency
Present
Absent
Unknown
Not assessed
Nocturia
Present
Absent
Unknown
Not assessed
Number of nighttime voids
Weak stream
Present
Absent
Unknown
Not assessed
Hesitancy
Present
Absent
Unknown
Not assessed
Straining
Present
Absent
Unknown
Not assessed
Intermittent stream
Present
Absent
Unknown
Not assessed
Incomplete emptying
Present
Absent
Unknown
Not assessed
Back
Next
Urinary retention
Present
Absent
Unknown
Not assessed
Urinary leakage
Present
Absent
Unknown
Not assessed
Leakage triggers
Visible blood in urine
Present
Absent
Unknown
Not assessed
Pelvic or bladder pain
Present
Absent
Unknown
Not assessed
Flank pain
Present
Absent
Unknown
Not assessed
Recurrent urinary infections
Present
Absent
Unknown
Not assessed
Onset and duration of urinary symptoms
Urologic history details
Review of systems
Fever
Present
Denied
Not assessed
Unable to obtain
Chills
Present
Denied
Not assessed
Unable to obtain
Fatigue
Present
Denied
Not assessed
Unable to obtain
Unintentional weight change
Present
Denied
Not assessed
Unable to obtain
Night sweats
Present
Denied
Not assessed
Unable to obtain
Rash
Present
Denied
Not assessed
Unable to obtain
Nonhealing skin lesion
Present
Denied
Not assessed
Unable to obtain
Vision change
Present
Denied
Not assessed
Unable to obtain
Eye pain
Present
Denied
Not assessed
Unable to obtain
Hearing change
Present
Denied
Not assessed
Unable to obtain
Nasal congestion
Present
Denied
Not assessed
Unable to obtain
Sore throat
Present
Denied
Not assessed
Unable to obtain
Chest pain
Present
Denied
Not assessed
Unable to obtain
Palpitations
Present
Denied
Not assessed
Unable to obtain
Leg swelling
Present
Denied
Not assessed
Unable to obtain
Shortness of breath
Present
Denied
Not assessed
Unable to obtain
Cough
Present
Denied
Not assessed
Unable to obtain
Wheeze
Present
Denied
Not assessed
Unable to obtain
Nausea
Present
Denied
Not assessed
Unable to obtain
Vomiting
Present
Denied
Not assessed
Unable to obtain
Abdominal pain
Present
Denied
Not assessed
Unable to obtain
Diarrhea
Present
Denied
Not assessed
Unable to obtain
Constipation
Present
Denied
Not assessed
Unable to obtain
Blood in stool
Present
Denied
Not assessed
Unable to obtain
Joint pain
Present
Denied
Not assessed
Unable to obtain
Muscle pain
Present
Denied
Not assessed
Unable to obtain
Back pain
Present
Denied
Not assessed
Unable to obtain
Headache
Present
Denied
Not assessed
Unable to obtain
Dizziness
Present
Denied
Not assessed
Unable to obtain
Back
Next
Weakness
Present
Denied
Not assessed
Unable to obtain
Numbness
Present
Denied
Not assessed
Unable to obtain
Syncope
Present
Denied
Not assessed
Unable to obtain
Heat/cold intolerance
Present
Denied
Not assessed
Unable to obtain
Excessive thirst
Present
Denied
Not assessed
Unable to obtain
Easy bruising
Present
Denied
Not assessed
Unable to obtain
Abnormal bleeding
Present
Denied
Not assessed
Unable to obtain
Depressed mood
Present
Denied
Not assessed
Unable to obtain
Anxiety symptoms
Present
Denied
Not assessed
Unable to obtain
Additional review of systems details
Male reproductive and prostate history
Back
Next
Erectile difficulty
Present
Absent
Unknown
Not assessed
Reduced sexual desire
Present
Absent
Unknown
Not assessed
Ejaculatory difficulty
Present
Absent
Unknown
Not assessed
Painful ejaculation
Present
Absent
Unknown
Not assessed
Blood in semen
Present
Absent
Unknown
Not assessed
Penile pain or curvature
Present
Absent
Unknown
Not assessed
Penile discharge or lesion
Present
Absent
Unknown
Not assessed
Testicular or scrotal pain
Present
Absent
Unknown
Not assessed
Testicular or scrotal swelling
Present
Absent
Unknown
Not assessed
Prior prostatitis
Present
Absent
Unknown
Not assessed
Enlarged prostate / BPH history
Present
Absent
Unknown
Not assessed
Prior prostate cancer
Present
Absent
Unknown
Not assessed
Back
Next
Prior infertility evaluation
Present
Absent
Unknown
Not assessed
Previous PSA value
Previous PSA unit
Previous PSA date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Previous prostate biopsy results
Previous prostate biopsy date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Prostate surgery or treatment
Vasectomy history
Yes
No
Unknown
Not assessed
Other genital or reproductive surgery
Testosterone or other hormone-treatment history
Fertility goals and details
Male reproductive-history comments
Prior laboratory results
Prior imaging findings
Prior urinary procedures
Prior catheter use history
Yes
No
Unknown
Submit history and ROS
Submit history and ROS
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