Offi ce Visit Checklist
Shareyourresponsestothesequestions
withyourdoctortoday.
Symptoms
Do you have pressure or pain
in your lower abdomen? YesNo
Do you have pain or
burning when you urinate? YesNo
Do you have a frequent or
urgent need to urinate? YesNo
Is there blood in your urine? YesNo
Do you have cloudy and
foul-smelling urine? YesNo
Do you get frequent urinary
tract infections? YesNo
Men: Do you have penis discharge? YesNo
Medications
List any medications you currently take, including
supplements and over-the-counter products:
2
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