Prostate or Testicular Exam Yearly for men starting at age 40 Other Date Location Result Physical Exam Foreign Travel History & Immunizations Tuberculosis (TB) skin test Diagnostic Imaging (X-Ray, Ultrasound, MRI, CT, Angiogram, etc.) Other Health History Please check any conditions you currently have or have had in the past year ONLY. General Gastrointestinal Eye/Ear/Nose/Throat Cardiovascular ¨ Chills ¨ Poor Appetite ¨ Bleeding gums ¨ Chest pain/pressure ¨ Depression ¨ Bloating ¨ Blurred vision ¨ High blood pressure ¨ Dizziness ¨ Bowel changes ¨ Crosses eyes ¨ Irregular heart beats ¨ Fainting ¨ Constipation <1 stool/day ¨ Difficulty of swallowing ¨ Low blood pressure ¨ Fever ¨ Diarrhea ¨ Double vision ¨ Poor circulation ¨ Forgetfulness ¨ Excessive hunger ¨ Ear ache ¨ Rapid heart beat ¨ Headache ¨ Excessive thirst ¨ Ear discharge ¨ Varicose veins ¨ Loss of sleep ¨ Gas ¨ Hay fever ¨ Edema ¨ Nervousness ¨ Hemorrhoids ¨ Hoarseness ¨ Numbness ¨ Indigestion ¨ Loss of hearing ¨ Sweats ¨ Nausea ¨ Nosebleeds ¨ Rectal bleeding ¨ Ringing in the ears ¨ Stomach pain ¨ Sinus infections ¨ Vomiting ¨ Vision “flashes” ¨ Vomiting blood ¨ Vision “halos” ¨ Parasites Name Date Health History (continued) Please check any conditions you currently have or have had in the past year ONLY. Respiratory Skin Muscle/Joint/Bone Genito-Urinary Pain, weakness, or numbness in: Shortness of breath Acne ¨ Blood in the urine ¨ ¨ Arms ¨ ¨ Persistent cough ¨ Bruise easily ¨ Frequent urination ¨ Back ¨ Wheezing ¨ Itching ¨ Lack of bladder control ¨ Feet ¨ Cough with blood ¨ Change in mole(s) ¨ Painful urination ¨ Hands ¨ Rash
Prostate or Testicular Exam Yearly for men starting at age 40 Other Date Location Result Physical Exam Foreign Travel History & Immunizations Tuberculosis (TB) skin test Diagnostic Imaging (X-Ray, Ultrasound, MRI, CT, Angiogram, etc.) Other Health History Please check any conditions you currently have or have had in the past year ONLY. General Gastrointestinal Eye/Ear/Nose/Throat Cardiovascular ¨ Chills ¨ Depression ¨ Dizziness ¨ Fainting ¨ Fever ¨ Forgetfulness ¨ Headache ¨ Loss of sleep ¨ Nervousness ¨ Numbness ¨ Sweats ¨ Poor Appetite ¨ Bloating ¨ Bowel changes ¨ Constipation <1 stool/day ¨ Diarrhea ¨ Excessive hunger ¨ Excessive thirst ¨ Gas ¨ Hemorrhoids ¨ Indigestion ¨ Nausea ¨ Rectal bleeding ¨ Stomach pain ¨ Vomiting ¨ Vomiting blood ¨ Parasites ¨ Bleeding gums ¨ Blurred vision ¨ Crosses eyes ¨ Difficulty of swallowing ¨ Double vision ¨ Ear ache ¨ Ear discharge ¨ Hay fever ¨ Hoarseness ¨ Loss of hearing ¨ Nosebleeds ¨ Ringing in the ears ¨ Sinus infections ¨ Vision “flashes” ¨ Vision “halos” ¨ Chest pain/pressure ¨ High blood pressure ¨ Irregular heart beats ¨ Low blood pressure ¨ Poor circulation ¨ Rapid heart beat ¨ Varicose veins ¨ Edema Name Date Health History (continued) Please check any conditions you currently have or have had in the past year ONLY. Respiratory Skin Muscle/Joint/Bone Genito-Urinary ¨ Shortness of breath ¨ Persistent cough ¨ Wheezing ¨ Cough with blood ¨ Acne ¨ Bruise easily ¨ Itching ¨ Change in mole(s) ¨ Rash Pain, weakness, or numbness in: ¨ Arms ¨ Back ¨ Feet ¨ Hands ¨ Blood in the urine ¨ Frequent urination ¨ Lack of bladder control ¨ Painful urination
WatersEdge-New-Patient-Health-Record%20with%20OfficeGuide%202016.docx