Abdominal/ Renal Questionnaire
Please do not complete this form until it's less than one week before your appointment.
Patient's name
*
First Name
Middle (Optional)
Last Name
Birth date
*
/
Month
/
Day
Year
Age
*
Gender
*
Female
Male
Referring MD
*
2nd MD to get report
Why has your MD ordered this exam?
*
When was your most recent abdominal ultrasound, CT, or MRI?
Where was that test performed?
Results of that test
Do you have:
Latex allergy
Abdominal pain
Nausea/vomiting
Weight loss
Recent urinary tract infection
Urinary frequency or urgency
Pain or burning with urination
Blood in the urine
Have you had:
Hepatitis or liver disease
Kidney stones or other disease
Abnormal blood work results
What abdominal or pelvic surgeries have you had?
What cancers have you had?
WOMEN ONLY: Menstrual status
Still having periods
Had hysterectomy
Perimenopausal
Went through menopause
WOMEN ONLY: First day of your last menstrual period
MEN ONLY: Has your doctor noted any prostate enlargement?
Yes
No
Do you have a known latex allergy?
*
* YES *
No
Any other pertinent information
Submit
Should be Empty: