Questionnaire for a Urologist

Personal information

Name: *

Phone number: *

Email:

Gender:

Age (in full years):

Height:

Weight:

City/Town and region where you are located:

Additional information you would like to share with your doctor (briefly):

Physical examination

Current body temperature, °C:

Maximum temperature in the last 24 hours, °C:

Blood pressure (if measured), mmHg:

Total urine output over the past 24 hours:

Blood in the urine:NoneRed-colored urine onceIntermittently red-colored urineBlood clots in the urine

If you experience urinary incontinence, indicate the number of pads used per day:

Number of nighttime urinations (from–to), times:

Uploading dataUpload photos of your latest lab results, ultrasound, CT and MRI reports, hospital discharge summaries, and any other medical examination results you have. Upload the data from discs or USB drives containing CT, MRI, or other examination results stored on digital media.

Questionnaire for a Urologist

Valeriy Kaminskiy

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Questionnaire for a Urologist

Valeriy Kaminskiy

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