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