Urology Intake Form
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Urology Intake Form
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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.
What's included
- AUA Symptom Score and urinary symptom assessment
- Prostate health and PSA screening history
- Kidney stone history with type and procedure documentation
- Medications list for urology medication reconciliation
- Insurance info collection and verification
- Consent agreement with electronic signature
- Medical conditions checklist
- Structured medication list with dosage and frequency tracking
- Insurance information collection with carrier and policy details
Who uses this template
- General urology and urologic surgery practices
- Prostate health and urologic oncology clinics
- Kidney stone and lithotripsy centers
- Female pelvic medicine and incontinence programs
All form fields
16 fields across 3 pages. Customize any field after signing up.
How to use the Urology Intake Form
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Urology Intake Form from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.
Setup steps
- 1Choose the template. Find the Urology Intake Form in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 16 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
Is the Urology Intake Form HIPAA compliant?
Yes. All Formisoft templates, including the Urology Intake Form, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 16 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.
Does this template work on mobile devices?
Yes. The Urology Intake Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
Sign up and start customizing the Urology Intake Form for your practice. Set up in minutes.
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