Genitourinary History |
Yes / No |
| Number of times that you urinate at night? |
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| Number of times that you urinate during the day? |
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| Any trouble starting the urine stream? |
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| Any trouble stopping the urine stream? |
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| Any pain with urination? |
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| Any difficulty holding urine? |
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| Any back pain related to urination? |
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| Ever had blood in urine? |
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| Ever had puffiness of face or eyes? |
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| Number of pregnancies. Age(s) of child (children). |
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| Number of miscarriages |
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| Number of abortions |
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