Specialist urologist · Ballito
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Dr. Eneshra PadayacheeUrology Inc.Book appointment
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Patient assessment

Prepare the details.
Share the full picture.

Complete the comprehensive assessment online or download the original four-page document before your appointment.

01

Printable document

Download the assessment pack.

Prefer to write by hand? Download the original four-page PDF, complete the patient sections and bring it to reception.

Download assessment pack · PDFPreview document in a new tab ↗
02

Online assessment

Complete it online.

Use the guided form below to share the same patient history and symptom information securely with the practice.

Start online form ↓
Before you start

Have your medical-aid details, medication list and relevant previous test information available. The clinician-only section is completed by the practice.

Comprehensive assessment

Your history,
clearly organised.

The questions mirror the patient-completed sections of the supplied assessment pack. Leave optional sections blank when they do not apply.

01

About you

Patient details

Complete the identifying and contact information from page one of the assessment pack.

Reason for your visit

How would you describe it?
02

Presenting symptoms

Urinary health

Select every symptom that applies and add the timing or detail you remember.

Urinary symptoms
Urine leakage?

Blood in the urine

Have you noticed blood?
Features of the bleeding

Urinary infection history

Select all that apply
03

Urological history

Stones, prostate and pelvic health

These sections are optional. Complete only those relevant to your symptoms or history.

Kidney, ureteric or bladder stones

Stone history
Side
Stone analysis or metabolic work-up?
Stone-related symptoms
Previous treatment

Prostate and male urinary symptoms

Select all that apply
Previous prostate assessment?
Previous prostate biopsy?

Sexual and reproductive health

Select all that apply
Spontaneous morning erections?

Testicular, scrotal and pelvic symptoms

Testicular or scrotal symptoms
Side
Incontinence or pelvic symptoms
04

Background

Medical and treatment history

Tell the practice about conditions, medication, allergies and investigations that may be relevant.

Medical history

Surgical and urological history

Previous procedure types

Medication and allergies

Known allergies?

Family and lifestyle history

Family history
Smoking
Alcohol

Previous investigations and results

Tests already performed
05

Confirmation

Review and submit

The clinician-only assessment and treatment-plan page will be completed by the practice during or after your consultation.

I confirm that the information I have supplied is accurate to the best of my knowledge. I understand that this form supports, but does not replace, a consultation or urgent medical assessment.

Your privacy matters.

This form contains personal health information. Submit it only from a private device and trusted connection. It is sent to the practice for assessment and administration and must not be used for emergencies.