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Valley Urology
6113 N. Fresno St.
Suite #101
Fresno, CA 93710
Ph (559) 438-2777
Fax (559) 438-4117

Please call for an Appointment

For new patients, please download and fill-out by hand the blank PDF patient forms, or type and then print them out using the online template
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REVIEW OF SYSTEMS
AS PART OF YOUR CURRENT PROBLEM, DO YOU HAVE :
     
CONSTITUTIONAL SYMPTOMS Yes No
FEVER/CHILLS/SWEATS
TIRED
HEADACHES
     
DO YOU HAVE NOW OR HAVE YOU EVER HAD :
     
ALLERGIC/IMMUNOLOGIC Yes No
HAYFEVER
DRUG ALLERGIES
OTHER
ENDOCRINE    
THYROID PROBLEMS
DIABETES
HORMONE IMBALANCE
TIRED/SLUGGISH
HOT FLASHES
OTHER
     
     
HAVE YOU EVER BEEN TREATED FOR :
     
INIEGUMENTARY Yes No
SKIN RASH
BOILS
PERSISTENT ITCH
OTHER
MISCULOSKELETAL    
JOINT PAIN
NECK PAIN
BACK PAIN
OTHER
EYES
BLURRED VISION
DOUBLE VISION
EYE PAIN
OTHER
EAR/NOSE/THROAT    
EAR INFECTION
SORE THROAT
SINUS PROBLEM
NOSE BLEEDS
OTHER
GENITOURINARY    
URINARY RETENTION
PAINFUL RETENTION
URINARY FREQUENCY
BLOOD IN URINE
OTHER
     
  Yes No
WEIGHT CHANGE
CHANGE IN APPETITE
OTHER
     
     
     
     
GASTROINTESTINAL Yes No
ABDOMINAL PAIN
NAUSEA/VOMITING/BLOOD
INDIGESTION/HEARTBURN
CONSTIPATION
DIARHEA
OTHER
RESPIRATORY    
WHEEZING
FREQUENT COUGH
SHORTNESS OF BREATH
OTHER
 
     
HEMATOLOGIC/LYMPHATIC Yes No
SWOLLEN GLANDS
BLOOD CLOTTING PROBLEMS
OTHER
 
CARDIOVASCULAR    
CHEST PAIN
HEART ATTACK
VERICOSE VEIN
HIGH BLOOD PRESSURE
PATIGUE
IRREGULAR HEARTBEAT
SHORTNESS OF BREATH
OTHER
NEUROLOGIC    
TREMORS
DIZZY SPELLS
NUMBNESS/TINGLING
SEIZURES
STROKES
PASSING OUT
OTHER
PSYCHOLOGICAL
DEPRESSION
ANXIETY
MENTAL ILLNESS
OTHER
     
NO CHANGE FROM PREVIOUS VISIT ON
 
REVIEWED BY : DATE :
 
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6113 N. Fresno St. Suite #101 Fresno, CA 93710 Ph: (559)438-2777, Fax: (559)438-4117 www.ValleyUrology.com