Urology Intake Form

The Urology Intake Form is designed specifically for urology practices, capturing the detailed genitourinary symptom history that urologists need for efficient patient evaluation. This template collects patient demographics alongside a thorough urinary symptom assessment using structured questions aligned with the AUA Symptom Score: frequency, urgency, nocturia, weak stream, intermittency, straining, incomplete emptying, and incontinence (stress, urge, overflow). Additional sections cover hematuria, dysuria, recurrent UTIs, kidney stone history (type, frequency, prior procedures), and pelvic pain.

Built for general urology, urologic oncology, female pelvic medicine, men's health, and pediatric urology practices, this form includes sections for prostate health (PSA history, DRE findings, BPH symptoms, prostate cancer screening), sexual health (erectile function, ejaculatory concerns, fertility history), prior urologic procedures (cystoscopy, TURP, lithotripsy, vasectomy, circumcision), imaging history (CT urogram, renal ultrasound, MRI), and a medication list covering alpha-blockers, 5-alpha reductase inhibitors, PDE5 inhibitors, and anticholinergics.

All fields are HIPAA-compliant and structured to support the urologic consultation workflow. The sensitive nature of urologic symptoms is addressed through clear, clinical language and optional fields that allow patients to share information at their comfort level. Pre-visit completion gives the urologist time to review the symptom pattern, prior workup, and determine the appropriate examination and diagnostic plan.