Patient Medical History

Manhattan Gramercy Park
201 East 19th Street
New York, NY 10003
Phone: 212-673-7300
Fax: 212-777-0097
Throgs Neck
3594 East Tremont Avenue
Bronx, NY 10465
Phone: 718-518-1108
www.aucofny.com
Steven M. Berman, M. D.
Mark Stein, M.D.
Patient Medical History
Today’s Date:_________________
Name:__________________________________
Date of Birth:_________________
Referring Doctor:_________________________ Primary Care Doctor:_______________________
Reason For Visit:
o
Frequent urinationo
Prostate check
o
Incontinenceo
Elevated PSA
o
Pelvic pain, bladder pain
oProstatitis
o
Interstitial cystitiso
Testicular pain
o
Urinary infectiono
Testicular mass
o
Frequent urinary infections
o
Erection problems
o
Kidney stonesoInfertility
o
Blood in urineo
Blood in semen
o Other:________________________
Medical History: o
I have no medical problems or illnesses
Please check off all medical problems and write down any that are not listed.
oArthritis
oAsthma
o
Cancer (List)
______________
______________
______________
Medications:
o Depression
o
Heart disease
oMS
oDiabetes o
High cholesterol
oParkinson’s
o Emphysema
o
Hypertension
oSeizures
o
Gastritis/ulcer
o
Irregular rhythm
oStroke
o Glaucoma o
Liver disease
oThyroid
oOther:___________
o______________o_________
o I take no medications
o yes (Include dosage, aspirin and non-prescription items)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Allergies or Sensitivities: Include medications, foods, dyes
o
I have no allergies
________________________________________________________________________
Surgery: o I have had no surgery
o yes (Include dates and side of body - i.e. left knee, right hernia)
________________________________________________________________________
________________________________________________________________________
Family History: Please list all serious illnesses in your immediate family
(parents, grandparents, siblings, children but not your spouse)
___________________
______________________________________
_______________
___________________
______________________________________
_______________
Social History:
Do you currently smoke tobacco? o No
o Yes
packs per day_____________________
Do you drink alcohol?
o No
o Yes
glasses per week__________________
Do you use recreational drugs?
o No
o Yes
which ones_______________________
Review of Systems: Are you currently experiencing any of the following symptoms?
General
Fever
Y N
Chills
Y N
Fatigue
Y N
Male and Female Genitourinary
Blood in urine
Y
Burning urination
Y
Flank pain
Y
Frequent urination night
Y
Frequent urination day
Y
Incontinence
Y
N
N
N
N
N
N
Skin Male Only
Bruising
Y N Erection problems
Y
N
Itching
Y N Penile lesions
Y
N
Rash
Y N Testicular mass
Y
N
Testicular pain
Y
N
Urethral Discharge
Y
N
ENT
Musculoskeletal
Headache
Y
N Back pain
Y
N
Ringing in ears
Y N Joint pain
Y
N
Nasal congestion
Y N Muscle pain
Y
N
Respiratory
Neurological
Shortness of breath
Y N Dizziness
Y
N
Coughing
Y N Seizures
Y
N
Wheezing
Y N Weakness
Y
N
CardiovascularEndocrine Chest pain
Y N Appetite change
Y
N
Palpitations
Y N Excessive thirst
Y
N
Swelling of feet
Y N
GastrointestinalHematology
Abdominal pain
Y N Blood clots
Constipation
Y N Enlarged lymph nodes
Nausea
Y N Prolonged bleeding
Vomiting
Y N
Y
Y
Y
N
N
N