Welcome to Our Practice

Transcription

1 Welcome to Our Practice Thank you for choosing Suncoast Urogynecology & Pelvic Reconstructive Surgery for your female pelvic needs. This practice is exclusively devoted to the treatment of women with pelvic floor disorders. Enclosed are some helpful information about what to expect, and a comprehensive questionnaire to maximize personal attention from the doctor during your visit. We look forward to meeting you soon! Before Your Visit: Patient educational information & background information about Dr. Mona McCullough are available on the Suncoast Urogynecology & Pelvic Reconstructive Surgery website: o You may also be interested to visit the American Urogynecology Society website for more information: o Please complete the enclosed New Patient Intake Questionnaire, which will take about 3 minutes of your time to complete. Please return the forms at least 3 days prior to your appointment, to avoid rescheduling: o HIPAA Secure Fax: (727) o Mail: 1814 Wellness Lane, New Port Richey, FL, Please also review the enclosed Patient Privacy Policy, sign the accompanying acknowledgement form, and return this form with the New Patient Intake Questionnaire. Appointment Policies You will receive an reminder one week and one day prior to your appointment If you are unable to attend your appointment, please reschedule at least 24hrs prior There is a $5 fee for No-Show appointments, without 24hrs prior notification We make every effort to see patients within 15min of the scheduled appointment time and hope you will assist our efforts by arriving on time or a little early If you are more than 15min late for your scheduled appointment, we will need to reschedule you for an alternate date/time to ensure adequate time to provide the personal attention you deserve for your problem If we have unanticipated schedule delays, we will do everything possible to respect your time & notify you in advance

2 What to bring to your appointment: Insurance card and co-payment Physician referral, if required by insurance provider Patient acknowledgment form & Completed New Patient Intake Questionnaire (enclosed) Copies of other medical records, if appropriate Current medication list/bottle(s) Driver s license or other identification Office Location: Trinity Professional Center, Building # Wellness Lane, New Port Richey, FL Parking is free for your convenience We are located about halfway between US19 & Suncoast Parkway, off Little Rd, approximately 1/2 mile south of SR 54 (just behind Walgreens on the corner of Little Rd & Mitchell Blvd)

3 What to Expect: Your picture will be taken for your electronic medical record You will be enrolled for online access to your medical records & given a PIN number You will be asked to use the private patient bathroom to collect a urine sample Family will be asked to remain in the waiting room until your exam is completed o We have a small waiting room with larger comfortable chairs intended for patients and one friend / family member each You will be seen in a private room where the medical assistant will measure your height, weight, temperature, and blood pressure The doctor will speak with you and review your New Patient Intake Questionnaire in a private patient room You will be asked to undress from the waist down for a physical & pelvic exam The pelvic exam includes measurements of your vaginal support while pushing (valsalva), evaluation of bladder emptying (may include a small catheter inserted temporarily into your bladder), evaluation of the pelvic muscles, evaluation for foreign bodies (typically, mesh implants) or previously undiagnosed masses You may lose urine or bowel contents during portions of the exam, which is actually important information to better help you & we hope to make you comfortable enough not to feel embarrassed if this happens After the exam, you may get dressed and invite your family member / friend to participate in the discussion of your exam findings, condition, additional studies, and treatment options with the doctor You will then be given paperwork to take back to the front desk for appointment scheduling, referrals, and/or printed patient educational materials as appropriate Additional appointments may be necessary for diagnostic tests, review of results, and/or detailed discussion of surgical treatment options Our office uses electronic medical records, which will be shared with your referring physician and any other physicians you would like to include in your care Our team is devoted to providing you with the highest quality of female pelvic medical and surgical care. If you think we can improve our care in any way, please notify us directly or leave suggestions & comments in our suggestion box to the left of the office exit door so we can address your concerns promptly. Sincerely, Mona McCullough, M.D., F.A.CO.G

4 HIPAA Privacy Authorization Form Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 16 and 164) 1. Authorization I authorize my prior health care providers to disclose the protected health information described below to Suncoast Urogynecology & Pelvic Reconstructive Surgery. 2. Effective Period (please check ONE) This authorization for release of information covers the period of healthcare from: A. to _. **OR** B. All past, present, and future periods. 3. Extent of Authorization (please check ONE and initial after) A. I authorize the release of my complete health record (including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse). **OR** B. I authorize the release of my complete health record with the exception of the following information (mark check in the boxes that apply) : Mental health records Communicable diseases (including HIV and AIDS) Alcohol/drug abuse treatment Other (please specify): 4. Medical Information Use: This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.

5 5. Right to Revoke: I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. 6. Conditions of Choice to Sign: I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization. 7. Information Disclosure: I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law. Signature of Patient or Personal Representative Printed Name of Patient or Personal Representative _ Date Signed Patient Date of Birth Person Signed Relation to Patient

6 1 Patient Name: Date of Birth: / / Home Address: Ethnicity: Home Phone: Cell Phone: Occupation: Work Phone: *** May we leave a message on your home/cell phone concerning your care?*** Yes No Main Support Person & Relation: Phone: Main Pharmacy for prescriptions: Phone: Please provide the following information to improve communication and coordination of care with your Primary Care Physician and your Specialty Physicians: Referring Physician (Chart notes will be sent): Primary Care Physician (if you have/had one): Specialty: Do you want our office notes sent? Yes No Name: Name: Address: Address: Phone #: Phone #: Fax #: Fax #: Ob/Gyn (if you have/had one): Cardiologist (if you have/had one): Do you want our office notes sent? Yes No Do you want our office notes sent? Yes No Name: Name: Address: Address: Phone #: Phone #: Fax #: Fax #: Other Physicians Taking Care of You: Other Physicians Taking Care of You: Specialty: Specialty: Do you want our office notes sent? Yes No Do you want our office notes sent? Yes No Name: Name: Address: Address: Phone #: Phone #: Fax #: Fax #:

7 2 Please provide the following information to ensure your insurance is properly billed: Primary Insurance: Insurance Company: Insurance Company Address: Insurance Company Phone#: Policy Holder Name (Exactly as Card): Policy Holder Date of Birth: Policy Holder Relation to Patient: Insured Social Security Number: Secondary Insurance: Insurance Company: Insurance Company Address: Insurance Company Phone#: Policy Holder Name (Exactly as Card): Policy Holder Date of Birth: Policy Holder Relation to Patient: Insured Social Security Number: Tertiary Insurance: Insurance Company: Insurance Company Address: Insurance Company Phone#: Policy Holder Name (Exactly as Card): Policy Holder Date of Birth: Policy Holder Relation to Patient: Insured Social Security Number:

8 3 Please provide as much medical history as possible, to improve your care. Important Past Medical History: 1. Do you have history of or take medicine for high blood pressure (hypertension)? Yes No 2. Do you have history of or take medicine for heart failure (CHF)? Yes No 3. Have you ever had a heart attack (MI), abnormal cardiac cath, or cardiac stents? Yes No 4. Do you have history of or take medicine for asthma? Yes No 5. Do you have history of or take medicine for COPD? Yes No 6. Do you have history of or take medicine for low thyroid (hypothyroid)? Yes No 7. Do you have history of or take medicine for high thyroid (hyperthyroid)? Yes No 8. Do you have history of or take medicine for hemorrhagic stroke (brain bleed)? Yes No 9. Do you have history of or take medicine for occlusive stroke (blood clot in brain)? Yes No 1. Do you have history of or use a machine/medicine for sleep apnea (OSA)? Yes No 11. Do you have history of or take medicine for DVT, PE (blood clots in lungs or veins)? Yes No 12. Do you have history of or take medicine for diabetes, pre- diabetes, sugar blood? Yes No 13. Do you or any blood relative have any bleeding disorders ( easy bleeders )? Yes No 14. Do you or any blood relative have a blood clotting disease requiring blood thinners? Yes No 15. Do you have a history of or take a medicine for kidney stones ( nephrolithiasis ) Yes No 16. Do you have congenital absence of one kidney (missing one kidney at birth)? Yes No Please list any other conditions you have been told you have or that you take medicine/treatment for:

9 4 Please provide as much surgical history as possible, to improve your care. Important Past Surgical History: 1. Have you had a hysterectomy (removal of the uterus)? Yes No 2. Have you had an oophorectomy (removal of one or both ovaries)? Yes No 3. Have you had abdominal or pelvic radiation? Yes No 4. Have you ever been told you had diverticulitis (infection of bowel outpouchings) Yes No 5. Have you ever been told you have endometriosis? Yes No 6. Have you ever been told you had adhesions/scar tissue in your abdomen/pelvis? Yes No 7. Have you ever had an abdominal or incisional or umbilical hernia repair? Yes No 8. Have you ever had your appendix removed (appendectomy)? Yes No 9. Have you ever had your gall bladder removed (cholecystectomy)? Yes No 1. Have you ever had a portion of bowel removed? Yes No 11. Have you ever had surgery on your bladder, ureters, kidneys, or urethra? Yes No 12. Have you ever had surgery using your own tissue for prolapse/incontinence? Yes No 13. Have you ever had vaginal surgery using mesh for prolapse/incontinence? Yes No 14. Have you ever had abdominal surgery using mesh for prolapse/incontinence? Yes No Please list all major surgeries and the approximate year:

10 5 Please list all prescription medications, over- the- counter medications, vitamins, herbs, and supplements you use including the name, dose, and prescribing doctor (if applicable): Name: Dose: Doctor: Name: Dose: Doctor: Name: Dose: Doctor: Name: Dose: Doctor: Name: Dose: Doctor: Name: Dose: Doctor: Name: Dose: Doctor: Name: Dose: Doctor: Name: Dose: Doctor: Name: Dose: Doctor: Name: Dose: Doctor: Name: Dose: Doctor: Name: Dose: Doctor: Name: Dose: Doctor: Name: Dose: Doctor: Please answer these questions about your allergies to improve your care: 1. Do you have an allergy or sensitivity to Latex? No Yes Reaction 2. Do you have an allergy or sensitivity to Iodine? No Yes Reaction 3. Do you have an allergy or sensitivity to Adhesive Tape? No Yes Reaction 4. Do you have an allergy or sensitivity to IV Contrast? No Yes Reaction 5. Do you have an allergy or sensitivity to Penicillins? No Yes Reaction 6. Do you have an allergy or sensitivity to Sulfas? No Yes Reaction Please list all other medical allergies or sensitivities & the associated reaction:

11 6 Please provide the following information to optimize your time with the physician: 1. Briefly describe the nature of the MAIN problem that brought you to our clinic today. 2. Please list any physicians you have seen for this problem & the evaluation or therapy completed. 3. When did the problem first start? 4. What have you tried for relief? 5. What makes the problem better? 6. What makes the problem worse? 7. How severe is the problem now? (How does the problem interfere with your daily life?) Urogynecology History Genitourinary 1. In a typical day, how many times do you urinate?: (frequency) 2. In a typical night, how many times do you awaken to urinate?: (nocturia) 3. Do you leak urine when you do not want to with activity (stress incontinence)?: Yes No If yes, with which activities? Cough Laugh Sneeze Exercise Stand Lift Sex 4. In a typical day, do you experience frequent, strong urges to urinate? (urgency) Yes No If yes, do you typically leak urine with the strong urges?(urgency incontinence) Yes No 5. In a typical week, do you have difficult/incomplete emptying of your bladder? Yes No 6. Do you typically wear pads, diapers, or liners for your urinary problems? Yes No 7. What volume of liquids do you drink in a typical day? (fluid intake) ounces 8. Have you ever used any overactive bladder medications (incontinence meds)? Yes No Medication Name: Duration of Use: Date Stopped: Medication Name: Duration of Use: Date Stopped: Medication Name: Duration of Use: Date Stopped:

12 7 Gastrointestinal 1. In a typical week, how many bowel movements do you have? 3. In a typical week, do you need to use laxatives or stool softeners most days? Yes No Medication Name: Dose: Number of Daily Doses: Medication Name: Dose: Number of Daily Doses: Medication Name: Dose: Number of Daily Doses: 4. In a typical week, do you have difficulty getting bowel movements out? Yes No 5. In a typical week, do you leak liquid stool when you do not want to? Yes No 6. In a typical week, do you leak solid stool when you do not want to? Yes No 7. In a typical week, do you leak gas/flatus when you do not want to? Yes No Gynecologic 1. Do you feel that your bladder, uterus, or vagina are falling out? Yes No 2. Are you sexually active at this time? Yes No 3. If you are not sexually active, is it because of pain with sex/intercourse? Yes No 4. If you are not sexually active, do you desire to keep the ability to have sex? Yes No Cancer Screening Date of Last Pap: Result: normal abnormal Have you ever had a bad or abnormal pap? Yes No Date of Last Mammogram: Result: normal abnormal Have you ever had a bad or abnormal pap? Yes No Date of Last Colonoscopy: Result: normal abnormal Have you ever had a bad or abnormal pap? Yes No Obstetric & Gynecologic History (# Deliveries: Full Term Pre Term ) # Abortions/Miscarriages: # Live Births: 1. How many Caesarian deliveries have you had? 2. How many Vaginal deliveries have you had? 3. How much did your largest baby weigh at birth? 4. Have you ever been told you had a tear into the rectum associated with child- birth? Yes No 5. How old were you when your period started? 6. How old were you when you had menopause?

13 8 **The next 7 questions are not necessary if you are post- menopausal (one full year without bleeding)** 1. What was the date of your last menstrual period? 2. How many days are between your menstrual cycles? 3. How many days does your menstrual cycle last? 4. Do you have pain associated with your menses? 5. What type of birth control are you using now? 6. Do you want additional information about birth control options? Yes No 7. Do you have other problems with your menstrual cycle that need to be discussed? Yes No If Yes, Explain: Habits 1. Do you currently smoke? Yes No 2. Have you ever smoked in the past? Yes No 3. Do you drink alcohol of any type (wine, beer, liquor, other)? Yes No 4. Do you use any street drugs? Yes No 5. Do you exercise at least 3 minutes, 3 times weekly? Yes No 6. Do you drink caffeine beverages? (coffee, tea, soda, other)? Yes No Family History 1. Does any blood- relative have Breast Cancer? Yes (Relationship: ) No 2. Does any blood- relative have Heart Disease? Yes (Relationship: ) No 3. Does any blood- relative have Ovarian Cancer? Yes (Relationship: ) No 4. Does any blood- relative have Colon Cancer? Yes (Relationship: ) No 5. Does any blood- relative have Vaginal Prolapse? Yes (Relationship: ) No 6. Does any blood- relative have Urine Incontinence? Yes (Relationship: ) No 7. Does any blood- relative have Uterine Cancer? Yes (Relationship: ) No 8. Does any blood- relative have Kidney Stones? Yes (Relationship: ) No

14 9 Constitutional: Review of Systems In the past 7 days, have you been bothered by any of the symptoms below? Fever Loss of appetite Fatigue Weight change Eyes: Eye pain Blurry vision Loss of vision ENMT: Swollen neck glands Loss of hearing Cardiovascular: Chest pain Fainting (syncope) Heart palpitations Heart murmur Leg swelling Respiratory: Shortness of breath Wheezing Frequent coughing Gastrointestinal: Abdominal pain Blood in stool Decreased Constipation Vomiting Diarrhea Nausea Musculoskeletal: Joint pain Difficulty walking Joint stiffness Muscle pain Back pain Muscle weakness Neurological: Frequent headaches Frequent dizziness Seizures Skin: Rash Itching Breast: Breast mass Breast pain Nipple discharge Psychiatric: Depression Anxiety Memory loss or confusion Endocrine: Diabetes Hyperthyroidism Hypothyroidism Patient signature Date Physician signature(above information was reviewed) Date

15 1 Urinary Questionnaire I (MESA) Instructions: These questions ask about symptoms you may have related to urine leakage. Please indicate the response that best represents how frequently you experience each symptom by placing an X under the appropriate response.. Part I: (Stress Symptoms) Does coughing gently cause you to lose urine? Does coughing hard cause you to lose urine? Does sneezing cause you to lose urine? Does lifting things cause you to lose urine? Does bending cause you to lose urine? Does laughing cause you to lose urine? Does walking briskly or jogging cause you to lose urine? Does straining, if you are constipated, cause you to lose urine? Does getting up from a sitting to a standing position cause you to lose urine? During the last 7 days, how many times did you accidentally leak urine when you were performing some physical activity such as coughing, sneezing, lifting or exercise? # of times

16 11 Urinary Questionnaire I (MESA) Instructions: These questions ask about symptoms you may have related to urine leakage. Please indicate the response that best represents how frequently you experience each symptom by placing an X under the appropriate response.. Part II: (Urge Symptoms) Some women receive very little warning and suddenly find that they are losing, or are about to lose, urine beyond their control. How often does this happen to you? If you can t find a toilet or find that the toilet is occupied, and you have an urge to urinate, how often do you end up losing urine or wetting yourself? Do you lose urine when you suddenly have the feeling that your bladder is very full? Does washing your hands cause you to lose urine? Does cold weather cause you to lose urine? Does drinking cold beverages cause you to lose urine? During the last 7 days, how many times did you accidentally leak urine when you had the urge or the feeling that you needed to empty your bladder, but you could not get to the toilet fast enough? # of times

17 12 PFDI Instructions: Please answer the following questions by placing an X in the appropriate box. If you ar unsure about how to answer a question, give the best answer you can. While answering these questions, please conside your symptoms over the last three months. Thank you for your help. 1 Do you usually experience pressure in the lower abdomen? No Yes Not at all Somewhat Moderately Quite a b 2 Do you usually experience heaviness or dullness in the pelvic area? No Yes Not at all Somewhat Moderately Quite a b 3 Do you usually have a bulge or something falling out that you can see or feel in the vaginal area? 4 Do you usually have to push on the vagina or around the rectum to have or complete bowel movement? 5 Do you usually experience a feeling of incomplete bladder emptying? 6 Do you ever have to push up on a bulge in the vaginal area with your fingers to start or complete urination? 7 Do you feel you need to strain If other than never, how too hard to have a bowel much does this movement? 8 Do you feel you have not If other than never, how completely emptied your much does this bowels at the end of a bowel movement? 9 Do you usually lose stool beyond your control if your stool is well formed? 1 Do you usually lose stool beyond your control if your stool is loose or liquid?

18 13 11 Do you usually lose gas from the rectum beyond your control? 12 Do you usually have pain when you pass your stool? 13 Do you experience a strong sense of urgency and have to rush to the bathroom to have a bowel movement? 14 Does a part of your bowel every pass through the rectum and bulge outside during or after a bowel movement? No Yes If other than never, how much does this Not at all Somewhat Moderately Quite a b 15 Do you usually experience frequent urination? 16 Do you usually experience urine leakage associated with a feeling of urgency that is a strong sensation of needing to go to the bathroom? 17 Do you usually experience urine leakage related to coughing, sneezing, or laughing? 18 Do you usually experience small amounts of urine leakage (that is, drops)? 19 Do you usually experience 4 difficulty emptying your bladder? 2 Do you usually experience pain or discomfort in the lower bother you abdomen or genital region?