Hydrocele Diagnostic Evaluation Form
Use this form to collect key clinical information for evaluating possible hydrocele before examination or follow-up.
Patient Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Sex at Birth / Gender
*
Female
Male
Intersex
Prefer not to say
Prefer to self-describe
Preferred Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Clinical Symptoms and History
Primary reason for visit/concern
*
Scrotal symptoms present
*
Swelling
Discomfort
Heaviness
Pain
Sudden enlargement
Other
How long have the symptoms been present?
*
Please Select
Less than 1 week
1 to 4 weeks
1 to 3 months
More than 3 months
Intermittent/unsure
Other
Symptom trend
*
Worsening
Stable
Improving
Intermittent
Relevant history of prior groin/scrotal conditions, surgery, injury, or infection
Prior groin or scrotal condition
Prior groin or scrotal surgery
Groin or scrotal injury
Prior infection
No relevant history
Other
Diagnostic Review and Consent
Consent to clinical examination and diagnostic evaluation
*
Yes, I consent
No, I do not consent
Clinician notes or observations
Submit
Should be Empty: