LPFP Med Update: Male 18+


Patient first name:

Last name:

Date of birth 
(enter as MM/DD/YYYY or click to use the calendar): 

Appointment date
(MM/DD/YYYY or click to use the calendar):

Provider:


Medical History Update

1. Please list any new medical problems since your last physical examination here.
 

2. Please list any medical concerns you wish to address at this visit:
 

3. Have you seen a specialist or other healthcare provider since your last visit? 

 

   If yes, who did you see and what for? (Please sign a Release of Information form at the front desk)
  

Over the past two weeks, how often have you:

4. Felt little interest or pleasure in doing things? (choose one)
 

5. Felt down, depressed, or hopeless? (choose one)
 

6. Are you sexually active?

7. Are you currently sexually active with more than one partner?

If Yes, circle one:

8. Would you like STD/STI screening today?

 

9. When was your last prostate exam?

What was your last PSA?

10. Have you ever had an abnormal prostate exam?

11. Have you noticed swelling/enlargement of your testicles?

12. Are you having difficulty urinating?

13. Do you have any blood in your urine?

14. Are you having difficulty with erections?

15. Have you had your stool tested for blood in the last year?

16. Do you take a baby aspirin daily?

17. Have you ever had a colonoscopy?

If yes, when and what were the results?

18. Have you had any rectal bleeding?

19. Have you ever had an exercise treadmill or other heart test performed?

If yes, when and what type of test?

20. Please list any new medical problems your relatives have had since your last exam:

Father:

Mother:

Siblings:

Children/Other:

 

Patient or Guardian Signature:

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Document name: LPFP Med Update: Male 18+
Unique Document ID: e3cb051bf344703509d318bc357524ae36a04123
Timestamp Audit
January 9, 2017 12:12 pm MSTLPFP Med Update: Male 18+ Uploaded by Chris Madden - lpfp@myupdox.com IP 50.194.156.193