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




You may feel embarrased to talk to your doctor about urinary problems. But, like gray and thinning hair, such problems are a part of aging. One of the causes of urinary symptoms in men over 50 is a treataoic condition called benign prostatic hyperplasia (BPH). In fact, It has been estimated that by the age of 80, 1 in every 4 males in the US will require treatment of their urinary symptoms caused by BPH.

Take this quiz to help you and your doctor decide whether you could benefit from a BPH treatment.

TAKING THE QUIZ (Please circle the answer that best represents your response to each of the following questions. The questions are designed to gauge the severity of any symptoms you may be experiencing.)

Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always Patient Score

1. INCOMPLETE EMPTYING (Over the past month, how often have you had a sensation of not emptying your bladder completely after you have finished urinating?)

2. FREQUENCY (Over the past month, how often have you had to urinate again less than 2 hours after you have finished urinating?)

3. INTERMITTENCY (Over the past month, how often have you found you stopped and started again several times when you urinated?)

4. URGENCY (Over the past month, how often have you found it difficult to postpone urination?)

5. WEAK STREAM (Over the past month, how often have you had a weak urinary stream?)

6. STRAINING (Over the past month, how often have you had to push or strain to begin urination?)

7. NOCTURIA (Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?)

Your Total Score

7. QUALITY OF LIFE DUE TO URINARY SYMPTOMS (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?)

Delighted Pleased Mostly satisfied Mixed Mostly dissatisfied Unhappy Terrible

Adapted from Barry MJ. et al. The American Urological Association symptom index for benign prostatic hyperplasia. J Urol. 1992:148:1549-1557.

SCORING THE QUIZ: Add the numbers from your answers to questions 1 through 7. The maximum possible score is 35. The final question will help you judge how you feel about your symptoms.

PLEASE NOTE: This test is used to measure the severily of your symptoms. It is not a diagnostic test. In other words, it will not tell you whether or not you have BPH. Talk to your doctor to determine whether your symptoms are due to BPH.
Remember: This information is not intended as a substitute for medical treatment.


Sexual Health Inventory For Men


PATIENT INSTRUCTIONS

Sexual health is an important part of an individual's overall physical and emotional well-being. Erectile dysfunction, also known as important, is one type of very common medical condition affecting sexual health. Fortunately, there are many different treatment options for erectile dysfunction. This questionnaire is designed to help you and your doctor identify if you may be experiencing erectile dysfunction. If you are, you may choose to discuss treatment options with your doctor.

Each question has several possible responses. Circle the number of the response that best describes your own situation. Please be sure that you select one and only one response for each question.


OVER THE PAST 6 MONTHS:
1. How do you rate your confidence that you could get and keep an erection?
Very low
Low
Moderate
High
Very high
2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?
No sexual activity
Almost never or never
A few times (much less than half the time)
Sometimes (about half the time)
Most times (much more than half the time)
Almost always or always
3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?
Did not attempt intercourse
Almost never or never
A few times (much less than half the time)
Sometimes (about half the time)
Most times (much more than half the time)
Almost always or always
4. When you had erections with sexual stimulation, how difficult was it to maintain your erection to completion of intercourse?
No sexual activity
Extremely difficult
Very difficult
Difficult
Slightly difficult
Not difficult
2. When you attempted sexual intercourse, how often was it satisfactory for you?
Did not attempt intercourse
Almost never or never
A few times (much less than half the time)
Sometimes (about half the time)
Most times (much more than half the time)
Almost always or always

Add the numbers corresponding to question 1-5. If your score is 21 or less, you may want to speak with your doctor.