MESA UROLOGISTS

If you are a women

Note at all Occasionally About once a
day
About three
times a day
About half the
time
Almost Always Score
Urgency- How often do you have a strong sudden urge to urinate that makes you fea you will leak urine if you can't get to a bathroom immediately?
Urgency Incontinence- How often do you leak urine after feeling an urge to go?
None Drops 1 Teaspoon 1 Tablespoon 1/4 Cup Entire Bladder Score
Incontinence- How much urine do you think usually leaks?
1-6 times 7-8 times 9-10 times 11-12 times 13-14 times 15 or more times Score
Frequency- How many times do you urinate during the day?
None 1 times 2 times 3 times 4 times 5 times or more Score
Wake to urinate- How many times do you usually get up each night to urinate?
Your Total
Score
Quality of life due to urinary symptoms
Delighted Mostly Satisfied Mixed Mostly Dissatisfied Unhappy Terrilbe
If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that?


Mesa Urologists, P.C.

Medical History Questionnaire Annual UPDATE

***ALL UNANSWERED QUESTIONS WILL BE ASSUMED TO BE NEGATIVE***


NEW HEALTH PROBLEMS    Since NEW SURGERIES    Date
NEW HOSPITALIZATION    Date NEW INJURIES    Date
List all drugs you presently use regularly or take occasionally
MEDICATION Strength Dose
*If you have a pre-printed list of your current medication. we will be happy to make a copy*
NEW ALLERGIES

Are you allergic to
   

   
Please provide approximate date of the most recent events of the following if applicable:

List other allergies