Epididymitis Physical Exam Form
Document patient symptoms, history, and physical findings for epididymitis evaluation.
Patient Full Name
*
First Name
Last Name
Date of Examination
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Onset and Duration of Symptoms
*
Primary Symptoms Present
*
Scrotal pain
Scrotal swelling
Erythema
Dysuria
Fever/chills
Urethral discharge
Other
Relevant Past Medical History
Prior episodes of epididymitis
Recent urinary tract infection
Recent sexual activity
Recent instrumentation (e.g., catheterization)
Other
Physical Exam Findings
*
Epididymal tenderness
Testicular swelling
Induration
Erythema
Reactive hydrocele
Normal exam
Other
Urinalysis Performed?
Yes
No
Clinical Impression / Plan
*
Examiner Name
*
Submit Exam
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