Main/Chief Complaint:
How long ago did the complaint start?
How do you characterize your complaint?
Intermittent/On-and-Off
Continuous/Persistent
Other Urologic Symptoms: VOIDING:
Delayed start of
urination
Pain during urination
Weak urination
Inability to hold
urination
Continuous urination
Frequent daytime urination
Frequent nighttime urination
Other Urologic Symptoms: URINARY ABNORMALITIES:
Bloody or tea-colored
urine
Sand in the urine
cloudy urine
Passage of stone
feces or air in urine
Other Urologic Symptoms: SEXUAL SYMPTOMS:
Inability to achieve or
sustain penile erection for sexual intercourse
Bloody ejaculate
Painful ejaculation
Premature ejaculation
Decreased or loss of
desire to have sex
Other General Symptoms:
Fever
Chills
Weakness
Nausea or dizziness
Vomiting
Weight loss
Other Symptoms/Previous Procedures Undertaken/Other Medical Diseases/Laboratory
or Imaging Results:
How may we help you? (Diagnosis, Treatment, Second Opinion, Explanation of
Disease Process, etc.)
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