Urology Testing Pathology Assessment Form
Use this form to collect urology testing and pathology assessment details, symptoms, history, and related clinical information for review.
Patient Information
Patient Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Sex at Birth
Please Select
Female
Male
Intersex
Prefer not to say
Other
Gender Identity
Please Select
Woman
Man
Non-binary
Transgender
Prefer not to say
Other
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method
*
Phone
Email
Text Message
Either Phone or Email
Assessment Reason and Urology Symptoms
Primary reason for assessment
*
Current urology-related symptoms
Pain
Burning
Urgency
Frequency
Retention
Hematuria
Incontinence
Nocturia
Difficulty urinating
Other
Symptom onset date
-
Month
-
Day
Year
Date
Symptom frequency
Please Select
Constant
Intermittent
Occasional
Daily
Several times per day
Nightly
Other
Symptom trend
Improving
Worsening
Unchanged
Pain and Symptom Severity
Pain or discomfort location
*
Pelvic
Flank
Lower abdominal
Testicular
Groin
Penile
Perineal
Other
Pain severity
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
How much have symptoms interfered with daily activities?
1
2
3
4
5
Medical and Urology History
Prior urology conditions
Kidney stones
Recurrent urinary tract infections
Prostate issues
Bladder issues
Urinary retention
Frequent urination
Blood in urine
Other
Previous urinary tract surgeries or procedures
Catheterization
Cystoscopy
Stone removal
Prostate procedure
Bladder procedure
Kidney procedure
Stent placement
Other
History of kidney stones
No
Yes
Unsure
History of recurrent urinary tract infections
No
Yes
Unsure
Cancer history relevant to urology
Prior similar pathology assessments or additional details
Testing, Imaging, and Pathology Details
Prior tests or studies performed
*
Urinalysis
Urine culture
Blood work
Ultrasound
CT scan
MRI
Cystoscopy
Biopsy
Pathology report review
Other
Specimen or source type
Test date
-
Month
-
Day
Year
Date
Requesting clinician
Upload pathology or imaging report
Upload a File
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Relevant findings or report summary
Medications, Allergies, and Current Treatment
Current medications
Current treatments
Antibiotics
Blood thinners
Hormone therapy
Pain medication
Other
Allergies or adverse reactions
Medications
Latex
Food
Environmental
No known allergies
Other
Allergy details and reaction notes
Referring Provider and Clinical Notes
Referring/Ordering Provider Name
*
First Name
Middle Name
Last Name
Clinic/Facility Name
*
Provider Contact Information
Please enter a valid phone number.
Format: (000) 000-0000.
Clinical Notes or Special Instructions for Pathology Review
Submit Assessment
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