New Urogynecology Patient Intake Form

Please complete this brief history to assist me in providing you with the best care possible.
This form will be added to your medical record.

1 Step 1

Name

Preferred Name

Date of Birth

Who referred you?

Reason for visit

Pharmacy Name

Address

Phone

Gynecologic History

Date of last menstrual period

Age at 1st period (years)

My period usually occurs every __ days

lasts for __ days

Age at menopause

Do you have a history of:

Ovarian cystsFibroidsAbnormal Pap testSexually Transmitted Infection

If yes, please provide date and describe

0 /

Have you ever used oral contraceptives? (If so, for how many years?)

Have you ever used hormone replacement therapy? (If so, for how many years?)

Are you sexually active?

YesNo

Any problems?

Total number of pregnancies

# of Vaginal deliveries

Cesarean deliveries

Miscarriages

Abortions

Ectopic pregnancies

Pregnancy complications

Obstetrics History

Deliveries:

Vaginal delivery dates:

Cesarean section delivery dates:

Infant birth weights:

Foreceps/Vacuum

YesNo

Episiotomy/Laceration

YesNo

Current Medications

(include vitamins, herbs and other supplements)

Please review your attached medication list. Please add/remove medications based on what you currently take.

1. Name of medication, Dosage, How often?

2. Name of medication, Dosage, How often?

3. Name of medication, Dosage, How often?

Allergies

Are you allergic to any medications?

NoYes

If yes, Please specify the medication and reaction

0 /

Medical History

(either now or in the past/detail below with year of diagnosis and treatment given)

AsthmaCancerCardiac diseaseDiabetesHypertension / high blood pressure

Inflammatory bowel diseaseLupusOsteoporosis / osteopeniaStrokeReflux (GERD)

Hyperlipidemia / cholesterolIrritable bowel syndromeThrombotic disorder (blood clots)Thyroid disease (low /high)

Psychiatric diagnosis

AnxietyDepressionBipolar disorderOther:

Please mention

0 /

Details about year of diagnosis and treatment given

0 /

Name

Date of visit

Surgical History

1. Name of procedure, Date and Reason for procedure

2. Name of procedure, Date and Reason for procedure

3. Name of procedure, Date and Reason for procedure

Family History

Do you have a family member with any of the following cancersIf yes please list which family member and age of diagnosis

Breast cancerOvarian cancerUterine/endometrial cancerProstate cancerPancreatic cancerColon cancerMelanomaOther cancer

Specify Other Cancer/ Please list which family member and age of diagnosis

0 /

Mother:

LivingDeceased

Cause of death

Father:

LivingDeceased

Cause of death

Siblings: Number living:

Number deceased:

Cause

Social History

Do you exercise? If so, what do you do?

Occupation

Marital Status

Do you smoke?

How many packs a day?

If you quit, when was this?

Do you drink alcohol?

How many drinks per week?

Any other drugs?

Which other drugs?

Review of systems:

Are you experiencing any of the following symptoms?

Constitutional

NoWeight lossWeight GainFeverFatigue

Eye Problems

NoVision changesGlassesContactsOther

Ear, Nose, Throat

NoUlcersSinusitisHeadacheHearing problems

Cardiovascular

NoChest painLeg swellingPalpitationsOther

Respiratory

NoWheezingCoughShortness of breathOther

Gastrointestinal

NoDiarrheaConstipationNauseaVomiting

Urinary

NoPainful urinationUrgencyFrequencyBloody urine

Skin/Breast

NoBreast painNipple dischargeBreast massSkin rash

Neurological

NoFaintingSeizuresNumbnessTrouble Walking

Psychiatric

NoDepressionAnxietyOther

Blood/Lymph

NoEasy bruisingAbnormal bleedingSwollen glandsOther

Muskuloskeletal

NoWeaknessPainOther

Physicians

Medical / primary care physician:

Phone

Obstetrician / Gynecologist:

Phone

Cardiologist:

Phone

Other physician:

Phone

THE FOLLOWING STANDARDIZED QUESTIONNAIRES DIAGNOSE/SCREEN FOR PELVIC FLOOR DISORDERS AND MAY ADDRESS THE SAME CONDITION IN REPETITION. PLEASE FILL THE QUESTIONNAIRES OUT ENTIRELY TO ENHANCE OUR CARE FOR WOMEN AFFECTED BY THESE SENSITIVE QUALITY-OF-LIFE DISORDERS.

1. How often do you experience urinary leakage?

NeverLess than once a monthA few times a monthA few times a weekEvery day and/or night

2. How much urine do you lose each time?

DropsSmall splashesMore

INSTRUCTIONS: Following are a list of questions about you and your partner’s sex life. All information is strictly confidential. Your confidential answers will be used only to help doctors understand what is important to patients about their sex lives. Please mark the box that best answers the question for you. While answering the questions, consider your sexuality over the past six months. Please mark only one box per question.

1. How frequently, do you feel sexual desire? This feeling may include wanting to have sex, planning to have sex, feeling frustrated due to lack of sex, etc.

AlwaysUsuallySometimesSeldomNever

2. Do you climax (have an orgasm) when having sexual intercourse with your partner?

AlwaysUsuallySometimesSeldomNever

3. Do you feel sexually excited (turned on) when having sexual activity with your partner?

AlwaysUsuallySometimesSeldomNever

4. How satisfied are you with the variety of sexual activities in your current sex life?

AlwaysUsuallySometimesSeldomNever

5. Do you feel pain during sexual intercourse?

AlwaysUsuallySometimesSeldomNever

6. Are you incontinent of urine (leak urine) with sexual activity?

AlwaysUsuallySometimesSeldomNever

7. Does fear of incontinence (either stool or urine) restrict your sexual activity?

AlwaysUsuallySometimesSeldomNever

8. Do you avoid sexual intercourse because of bulging in the vagina (either the bladder, rectum, or vagina falling out)?

AlwaysUsuallySometimesSeldomNever

9. When you have sex with your partner, do you have negative emotional reactions such as fear, disgust, shame, or guilt?

AlwaysUsuallySometimesSeldomNever

10. Does your partner have a problem with erections that affects your sexual activity?

AlwaysUsuallySometimesSeldomNever

11. Does your partner have a problem with premature ejaculation that affects your sexual activity?

AlwaysUsuallySometimesSeldomNever

12. Compared to orgasms you have had in the past, how intense are the orgasms you have had in the past six months?

Much less intenseLess intenseSame intensityMore intenseMuch more intense

INSTRUCTIONS: Please answer these questions by selecting the appropriate box. If you are unsure about how to answer a question, give the best answer you can. While answering these questions, please consider your symptoms over the last 3 months.

1. Do you usually experience pressure in the lower abdomen?

YesNo

If yes, how much does this bother you?

Not at AllSomewhatModeratelyQuite a bit

2. Do you usually experience heaviness or dullness in the pelvic area?

YesNo

If yes, how much does this bother you?

Not at AllSomewhatModeratelyQuite a bit

3. Do you usually have a bulge or something falling out that you can see or feel in the vaginal area?

YesNo

If yes, how much does this bother you?

Not at AllSomewhatModeratelyQuite a bit

4. Do you usually have to push on the vagina or around the rectum To have or complete a bowel movement?

YesNo

If yes, how much does this bother you?

Not at AllSomewhatModeratelyQuite a bit

5. Do you usually experience a feeling of incomplete bladder emptying?

YesNo

If yes, how much does this bother you?

Not at AllSomewhatModeratelyQuite a bit

6. Do you ever have to push up on a bulge in the vaginal area with your fingers to start or Complete urination?

YesNo

If yes, how much does this bother you?

Not at AllSomewhatModeratelyQuite a bit

7. Do you feel you need to strain too hard to have a bowel movement?

YesNo

If yes, how much does this bother you?

Not at AllSomewhatModeratelyQuite a bit

8. Do you feel you have not completely emptied your bowels at the end of a bowel movement?

YesNo

If yes, how much does this bother you?

Not at AllSomewhatModeratelyQuite a bit

9. Do you usually lose stool beyond your control if your stool is well formed?

YesNo

If yes, how much does this bother you?

Not at AllSomewhatModeratelyQuite a bit

10. Do you usually lose stool beyond your control if your stool is loose or liquid?

YesNo

If yes, how much does this bother you?

Not at AllSomewhatModeratelyQuite a bit

11. Do you usually lose gas from the rectum beyond your control?

YesNo

If yes, how much does this bother you?

Not at AllSomewhatModeratelyQuite a bit

12. Do you usually have pain when you pass your stool?

YesNo

If yes, how much does this bother you?

Not at AllSomewhatModeratelyQuite a bit

13. Do you experience a strong sense of urgency and have to rush to the bathroom to have a bowel movement?

YesNo

If yes, how much does this bother you?

Not at AllSomewhatModeratelyQuite a bit

14. Does a part of your bowel ever pass through the rectum and bulge outside during or after a bowel movement?

YesNo

If yes, how much does this bother you?

Not at AllSomewhatModeratelyQuite a bit

15. Do you usually experience frequent urination?

YesNo

If yes, how much does this bother you?

Not at AllSomewhatModeratelyQuite a bit

16. Do you usually experience urine leakage associated with a feeling or urgency that is a strong sensation of needing to go to the bathroom?

YesNo

If yes, how much does this bother you?

Not at AllSomewhatModeratelyQuite a bit

17. Do you experience urine leakage related to coughing, sneezing, or laughing?

YesNo

If yes, how much does this bother you?

Not at AllSomewhatModeratelyQuite a bit

18. Do you usually experience small amounts of urine leakage (that is, drops)?

YesNo

If yes, how much does this bother you?

Not at AllSomewhatModeratelyQuite a bit

19. Do you usually experience difficulty emptying your bladder?

YesNo

If yes, how much does this bother you?

Not at AllSomewhatModeratelyQuite a bit

20. Do you usually experience pain or discomfort in the lower abdomen or genital region?

YesNo

If yes, how much does this bother you?

Not at AllSomewhatModeratelyQuite a bit

INSTRUCTIONS : Some women find that bladder, bowel, or vaginal symptoms affect their activities, relationships, and feelings. For each question, select a response that best describes how much your activities, relationships or feelings have been affected by your bladder, bowel, or vaginal symptoms or conditions over the last 3 months. Please be sure to mark an answer for each question.

How do symptoms or conditions relating to the Following (Bladder or urine Bowel or rectum Vagina or pelvis) Usually affect your

1. Ability to do household chores (cooking, housecleaning, laundry)?

Bladder or Urine