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Address: 3110 S. Durango Drive, Suite 200 Las Vegas, NV 89117

Phone: 702-629-2986

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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
Gynecologic History
Do you have a history of:
Are you sexually active?
Obstetrics History

Deliveries:

Foreceps/Vacuum
Episiotomy/Laceration
Current Medications

(include vitamins, herbs and other supplements) 

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


Allergies
Are you allergic to any medications?
Medical History

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

Psychiatric diagnosis
Surgical History
Family History
Do you have a family member with any of the following cancersIf yes please list which family member and age of diagnosis
Mother:
Father:
Social History
Review of systems:

Are you experiencing any of the following symptoms?

Constitutional
Eye Problems
Ear, Nose, Throat
Cardiovascular
Respiratory
Gastrointestinal
Urinary
Skin/Breast
Neurological
Psychiatric
Blood/Lymph
Muskuloskeletal
Physicians

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?
2. How much urine do you lose each time?

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.
2. Do you climax (have an orgasm) when having sexual intercourse with your partner?
3. Do you feel sexually excited (turned on) when having sexual activity with your partner?
4. How satisfied are you with the variety of sexual activities in your current sex life?
5. Do you feel pain during sexual intercourse?
6. Are you incontinent of urine (leak urine) with sexual activity?
7. Does fear of incontinence (either stool or urine) restrict your sexual activity?
8. Do you avoid sexual intercourse because of bulging in the vagina (either the bladder, rectum, or vagina falling out)?
9. When you have sex with your partner, do you have negative emotional reactions such as fear, disgust, shame, or guilt?
10. Does your partner have a problem with erections that affects your sexual activity?
11. Does your partner have a problem with premature ejaculation that affects your sexual activity?
12. Compared to orgasms you have had in the past, how intense are the orgasms you have had in the past six months?

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?
If yes, how much does this bother you?
2. Do you usually experience heaviness or dullness in the pelvic area?
If yes, how much does this bother you?
3. Do you usually have a bulge or something falling out that you can see or feel in the vaginal area?
If yes, how much does this bother you?
4. Do you usually have to push on the vagina or around the rectum To have or complete a bowel movement?
If yes, how much does this bother you?
5. Do you usually experience a feeling of incomplete bladder emptying?
If yes, how much does this bother you?
6. Do you ever have to push up on a bulge in the vaginal area with your fingers to start or Complete urination?
If yes, how much does this bother you?
7. Do you feel you need to strain too hard to have a bowel movement?
If yes, how much does this bother you?
8. Do you feel you have not completely emptied your bowels at the end of a bowel movement?
If yes, how much does this bother you?
9. Do you usually lose stool beyond your control if your stool is well formed?
If yes, how much does this bother you?
10. Do you usually lose stool beyond your control if your stool is loose or liquid?
If yes, how much does this bother you?
11. Do you usually lose gas from the rectum beyond your control?
If yes, how much does this bother you?
12. Do you usually have pain when you pass your stool?
If yes, how much does this bother you?
13. Do you experience a strong sense of urgency and have to rush to the bathroom to have a bowel movement?
If yes, how much does this bother you?
14. Does a part of your bowel ever pass through the rectum and bulge outside during or after a bowel movement?
If yes, how much does this bother you?
15. Do you usually experience frequent urination?
If yes, how much does this bother you?
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?
If yes, how much does this bother you?
17. Do you experience urine leakage related to coughing, sneezing, or laughing?
If yes, how much does this bother you?
18. Do you usually experience small amounts of urine leakage (that is, drops)?
If yes, how much does this bother you?
19. Do you usually experience difficulty emptying your bladder?
If yes, how much does this bother you?
20. Do you usually experience pain or discomfort in the lower abdomen or genital region?
If yes, how much does this bother you?

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
Bowel or Rectum
Vagina or Pelvis

2. Ability to do physical activities such as walking, swimming, or other exercise?

Bladder or Urine
Bowel or Rectum
Vagina or Pelvis

3. Entertainment activities such as going to a movie or concert?

Bladder or Urine
Bowel or Rectum
Vagina or Pelvis

4. Ability to travel by car or bus for a distance of greater than 30 minutes away from home?

Bladder or Urine
Bowel or Rectum
Vagina or Pelvis

5. Participating in social activities outside your home?

Bladder or Urine
Bowel or Rectum
Vagina or Pelvis

6. Emotional health (nervousness, depression, etc.)?

Bladder or Urine
Bowel or Rectum
Vagina or Pelvis

7. Feeling frustrated?

Bladder or Urine
Bowel or Rectum
Vagina or Pelvis

INSTRUCTIONS: For each of the following, please indicate on average in the past month if you experienced any amount of accidental bowel leakage:

Gas
Mucus
Liquid stool
Solid stool

INSTRUCTIONS: Please check the box for the answer that best describes how you feel for each question:

1. How many times do you go to the bathroom during the day?
2a. How many times do you go to the bathroom at night?
b. If you get up at night to go to the bathroom does it bother you?
3. Are you currently sexually active?
4a. IF YOU ARE SEXUALLY ACTIVE, do you now or have you ever had pain or symptoms during or after sexual intercourse?
b. If you have pain, does it make you avoid sexual intercourse?
5. Do you have pain associated with your bladder or in your pelvis (vagina, lower abdomen, urethra, perineum)?
6. Do you have urgency after going to the bathroom?
7a. If you have pain, is it usually
b. Does your pain bother you?
8a. If you have urgency, is it usually
b Does your urgency bother you?
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+1 702-629-2986

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