Vulvar pain/problem Pain with intercourse
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- Victoria Holmes
- 5 years ago
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1 MEDICAL HISTORY- CONSULT Name: Birthdate: Date: PATIENT PREFERENCES: Primary Care Physician: Wh referred yu t ur ffice? Lcal Pharmacy and Phne Number: Mail Order Pharmacy: Imaging Center: Gwinnett Medical Center Eastside Emry Jhn s Creek Breast Care Specialists Nrtheast Gergia Nrthside Other REASON FOR VISIT: Check all that apply. Pelvic pain Abdminal pain Vaginal pain/prblem Vulvar pain/prblem Pain with intercurse Frequent UTI s Frequency Other If yu are here fr abdminal r pelvic pain Where is the pain? Please circle all that apply Right Left Bth/Bilateral Unsure Upper Lwer Suprapubic Midline Other: Which f the fllwing best describe the pain? Please circle all that apply Sharp Shting Stabbing Dull Achy Pressure Spasmdic Burning Fullness/Blating Radiating Other REVIEW OF SYSTEMS: Please circle any f these symptms that yu are currently experiencing. CONSTITUTIONAL: fever, chills GASTROINTESTINAL: abdminal pain, epigastric pain, nausea, vmiting, cnstipatin, diarrhea, rectal bleeding, rectal pain, leaking r stl GENITOURINARY: bladder pain, urethral pain, urinary urgency, urinary frequency (urinating mre than 8 times a day), pain with urinatin, bld in urine, getting up at night t urinate, leaking urine, vaginal pain, vulvar pain, vaginal discharge, vaginal dr, vaginal itching, vaginal burning, vaginal irritatin, lesins, bleeding SEXUAL: painful intercurse (deep), painful intercurse (upn penetratin), vaginal dryness MUSCULOSKELETAL: lwer back pain, upper back pain, thigh pain, grin pain ALLERGIES: Please list any drug allergies. Nne MEDICATIONS: Please list any medicatins that yu take: prescriptin, ver the cunter, and vitamins. IF YOU HAVE A LIST OF MEDICATIONS WITH YOU PLEASE ASK THE FRONT DESK TO MAKE A COPY AND SKIP THIS SECTION. Name Dsage Hw ften 1 Gwinnett s Prgressive Healthcare fr Wmen 771 Old Nrcrss Rd, Suite305, Lawrenceville, GA
2 HEALTH MAINTENANCE TESTING DATE RESULTS LOCATION MAMMOGRAM COLONOSCOPY BONE DENSITY PAP SMEAR GENETIC TESTING 1. Have yu ever had an abnrmal pap smear? 2. Are yu sexually active? a. If n, have yu ever been sexually active? b. If yes, have yu had any new sexual partners _ 3. Sexual rientatin: (please circle ne) Hetersexual Bisexual Hmsexual Transgender 4. What d yu use fr cntraceptin (t prevent pregnancy)? 5. D yu desire STD testing tday? MENSTRUATING WOMEN ONLY: First day f last perid Length f flw: Mnthly cycles: YES r NO Amunt f bleeding: (please circle ne) SCANT / LIGHT / MODERATE / HEAVY 1) # f heavy days: 2) Hw ld were yu when yu started yur perid? 3) Have yu had the HPV/Gardasil vaccinatin? MENOPAUSAL WOMEN ONLY: Age at menpause: Hrmne replacement therapy: (please circle ne) NEVER / CURRENT / PAST USE Have yu had any bleeding in the last year? OB HISTORY: Tell us abut yur pregnancies. Never Pregnant Number f Pregnancies Number f Deliveries 2 Date Outcme: Please circle Delivery type: please circle Full term / Preterm /Stillbirth /Miscarriage/Terminatin/Ectpic Vaginal/C- sectin Full term / Preterm /Stillbirth /Miscarriage/Terminatin/Ectpic Vaginal/C- sectin Full term / Preterm /Stillbirth /Miscarriage/Terminatin/Ectpic Vaginal/C- sectin Full term / Preterm /Stillbirth /Miscarriage/Terminatin/Ectpic Vaginal/C- sectin Full term / Preterm /Stillbirth /Miscarriage/Terminatin/Ectpic Vaginal/C- sectin Full term / Preterm /Stillbirth /Miscarriage/Terminatin/Ectpic Vaginal/C- sectin Gwinnett s Prgressive Healthcare fr Wmen 771 Old Nrcrss Rd, Suite305, Lawrenceville, GA
3 FAMILY HISTORY: Please circle any f the fllwing that affect a family member, indicate relatinship (i.e. Mther, Father, Brther, Sister, Grandparent, Aunt, Uncle) and if they are maternal r paternal. Disease Breast cancer Uterine cancer Cln/Rectal cancer Ovarian cancer Prstate cancer Has anyne in the family had genetic testing? Heart disease High bld pressure Strke Thyrid disease Diabetes Osteprsis Bleeding/Cagulatin disrder Fibrmyalgia Depressin Endmetrisis Chrnic pelvic pain Interstitial cystitis Irritable bwel Family Member SOCIAL HISTORY: Please answer ALL questins. Circle the ne that applies t yu r fill in the blank. Smking 1. Never/Current/ Past Use - > Hw many cigarettes daily? 2. Wuld like t quit? Yes/N Alchl Use: 1. Never/Occasinal/ Mderate/Heavy 2. Histry f alchl abuse? Yes/ N 3. Hw many days in the last year have yu had mre than 4 drinks in ne day? Drug Use: 1. Never / Current Use / Past Use 2. Rehab: Current / Past / Never Cuntry f Birth: Ethnic Backgrund: 1. Caucasian 3. African American 4. Latin 5. Native American 6. Asian 7. Pacific Islander 8. Jewish 9. Mediterranean 10. Eastern Eurpe 11. Western Eurpe 12. French Canadian 13. Other: Occupatin: Religin: Marital Status 1. Single/ Dmestic Partner/ Married/Separated/Divrced/ Widw Dmestic Vilence: 1. D yu feel safe at hme? Yes/N 2. D yu have a histry f emtinal/physical/sexual abuse? Yes/N Hbbies/Activities: Stress Level: 1. Lw/Medium/High SURGICAL HISTORY: Date Type f Surgery (Please circle thse dne fr pain) Surgen 3 Have yu ever been hspitalized fr anything ther than childbirth? Y/N Explain: Gwinnett s Prgressive Healthcare fr Wmen 771 Old Nrcrss Rd, Suite305, Lawrenceville, GA
4 Have yu had majr accidents such as fall r back injury? Y/N Explain: MEDICAL HISTORY: Please check any medical prblems CANCER (List Type) HEART DISEASE High Bld Pressure High Chlesterl Heart Attack Cardimypathy Murmur Pacemaker/Defibrillatr DERMATOLOGY Eczema Rsacea Vitilig ENT Meniere s Disease Tinnitus Hearing Lss Sleep Apnea ENDOCRINE Diabetes Ostepenia Osteprsis Thyrid Prblems GI Cln Plyps Irritable Bwel Syndrme Acid Reflux GYNECOLOGY Dysplasia Endmetrisis Fibrids Infertility PCOS HEMATOLOGY Vn Willebrand Disease Factr V Leiden Cagulatin Disrder DVT/Pulmnary Emblism Sickle Cell Disease/Trait INFECTIOUS DISEASE HIV Hepatitis Herpes HPV MRSA Infectin NEUROLOGIC Migraine Mental Retardatin Autism Multiple Sclersis Parkinsn s Neurpathy Seizures ORTHOPEDIC Ostearthritis PSYCHIATRIC ADD Anxiety Depressin Insmnia Biplar Disrder OCD PMS Anrexia PULMONARY Asthma Seasnal Allergies Pulmnary Fibrsis Emphysema COPD RHEUMATOLOGY Fibrmyalgia Lupus Gut Raynaud s Disease Sjgren Syndrme Sclerderma Chrnic Fatigue Syndrme Psriasis Rheumatid Arthritis UROLOGY Kidney Stnes Interstitial Cystitis Over Active Bladder DIAGNOSTIC TESTING: Please mark the evaluatin and testing that yu have had fr yur prblem and use the blanks t give us dates, prviders, r any pertinent infrmatin. 4 CULTURES Vaginal cultures Urine cultures Cervical cultures RADIOLOGY STUDIES Ultrasund CT Scan MRI GYNECOLOGIC Endmetrial bipsy Hysterscpy D&C Laparscpy PRIMARY CARE PROVIDER GASTROENTEROLOGY Endscpy Clnscpy UROLOGY Cystscpy Urdynamics Ptassium sensitivity Hydrdistentin ORTHOPEDIC RHEUMATOLOGY NEUROLOGY PSYCHIATRIC INFECTIOUS DISEASE PAIN MANAGEMENT PHYSICAL THERAPY Gwinnett s Prgressive Healthcare fr Wmen 771 Old Nrcrss Rd, Suite305, Lawrenceville, GA
5 PREVIOUS TREATMENTS: Circle thse treatments yu have used in the past. ANTI- SEIZURE MEDICATION amitriptyline lyrica gabapentin/neurntin ANTIHISTAMINES atarax/hydrxyzine benedryl zyrtec ANTI- AXIETY valium ativan xanax ANTIDEPRESSANTS dulxitine/cymbalta fluxetine/przac sertraline/zlft wellbutrin/ buprprin celexa/lexapr ANTIBIOTICS ciprflxin bactrim macrbid keflex BLADDER MEDICATIONS pyridium/phenazpyridine UTA/Uribel/ Urgesic Elmirn Cystprtek Ale Vera Dessert Harvest UROLOGY Bladder instillatins Urethral dilatin Hydrdistentin Interstim Btx Tibial nerve stimulatin (UrgentPC) GYNECOLOGY Luprn Birth cntrl pills/ patch/ring IUD Nexplann Dep prvera Danazl estrgen prgesterne lubricants/misturizers vulvar medicatins: lidcaine, gabapentin vaginal medicatins: flagyl/difucan/mnistat Other PAIN MEDICATION tylenl/acetmenphin mtrin/ibuprfen/ anaprx/ ultram narctics/perccet/ nrc/ PHYSICAL THERAPY Bifeedback Pelvic flr relaxatin Trigger pint injectins Massage TENS unit/electrical stimulatin Dilatrs Dry needling Accupuncture Diet Meditatin Exercise Herbal medicine Hmepathic medicine Nerve blck 5 MODIFYING FACTORS: Please lk at the fllwing list and mark if yu have nted whether there is imprvement Meditatin Massage Pain medicatin Relaxatin Ice Heat Full bladder Urinatin Empty bladder Bwel mvement Laxative/enema Rest Activity/exercise/mvement intercurse rgasm Cntact with clthing Stress Interstitial cystitis Allergies Diet/certain fds r beverages Other: HAVE NOT NOTICED/TRIED IMPROVES/HELPS MAKES IT WORSE Gwinnett s Prgressive Healthcare fr Wmen 771 Old Nrcrss Rd, Suite305, Lawrenceville, GA
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Medical Histry Althugh dental persnnel primarily treat the area in and arund yur muth, yur muth is a part f yur entire bdy. Health prblems that yu may have, r medicatin that yu may be taking, culd have
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Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information
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You may have a higher risk of bleeding if you take warfarin sodium tablets and:
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