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Patient Forms · Health History

Health History

Your medications, allergies, medical history and current symptoms — about 12 minutes. New patients can complete the full New Patient Packet (opens in a new tab) instead, which includes this form.

Send it online when you finish, or print it and bring it to your visit. What you send goes securely to our office’s patient system. Nothing is sent until you press Send, and nothing you type is saved on this device.

Start Print a blank copy (opens in a new tab)

Urological Consultants of Florida
12411 Biscayne Boulevard, North Miami, FL 33181 · (305) 672-4222 · www.miamiurologyconsultants.com

Health HistoryHX-1 · v2026.11.0

Health History

About 12 minutes · HX-1 · v2026.11.0

All fields are required unless marked (optional).

About you

MM/DD/YYYY

Sex listed on your insurance card

This shows the parts of the form that apply to you.

Why you're here

Describe the problem in your own words.

For example 5 ft 10 in

Medications and allergies
Current medications and doses (optional)

Include vitamins, supplements and blood thinners.

Allergies (optional)
Past medical history
Have you ever had any of these? Check all that apply. (optional)

Example: bladder cancer 2019, diabetes since 2010.

Past surgeries
Have you had any of these? Check all that apply. (optional)
List your procedures and surgeries, with the approximate year (optional)
Family history

Check any illness in your immediate family and tell us who had it (for example: father, sister).

Family history
Lifestyle
Smoking status (optional)

For example: 1 pack a day

Do you drink alcohol? (optional)
Type of alcohol (optional)
How many caffeinated drinks do you have each day? (optional)
Have you ever had a blood transfusion? (optional)

Some jobs involve chemicals or dyes that matter for bladder health.

This section is for some patients only.

Pregnancy history

For patients who have been pregnant or have a uterus.

Current symptoms

Check anything you have now.

Constitutional
Eyes
Ears, nose, mouth and throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurological
Blood and lymph

This section is for some patients only.

AUA Symptom Score

Seven questions about urination over the past month, and one about how you feel about it. Your score adds up as you go.

Circle or tick one answer per question. Score shown in brackets.

1. Incomplete emptying Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating?
2. Frequency Over the past month, how often have you had to urinate again less than two hours after you finished urinating?
3. Intermittency Over the past month, how often have you found you stopped and started again several times when you urinated?
4. Urgency Over the past month, how often have you found it difficult to postpone urination?
5. Weak stream Over the past month, how often have you had a weak urinary stream?
6. Straining Over the past month, how often have you had to push or strain to begin urination?
7. Nocturia Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?
Quality of life due to urinary symptoms If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?

AUA Symptom Score (questions 1–7)   of 35

Mild 0–7 · Moderate 8–19 · Severe 20–35 · Quality of life is scored 0–6 separately:  

AUA Symptom Index (Barry MJ et al., J Urol 1992). Questions 1–7 are scored 0–5 and added together (0–35); the quality-of-life question is scored 0–6 and reported separately.

Confirm and sign

Review and send

When you have finished, send your answers to our office. Nothing is sent until you press Send to the practice. You can also print your form and bring it instead.

Sent securely to our office’s patient system. This page does not save what you type on this device.

What to bring to your visit

  • Photo ID
  • Your insurance card(s)
  • Your medication list or bottles
  • Any referral or recent records, if you have them

Questions? Call (305) 672-4222, Monday–Friday, 9:00 am – 5:00 pm.