CENTER FOR ADULT PELVIC HEALTH & CONTINENCE CARE

Transcription

1 CENTER FOR ADULT PELVIC HEALTH & CONTINENCE CARE 500 Red Creek Drive - Building Suite 120 Rochester, New York Telephone (585) Fax (585) Website: Pelvichealth.urmc.edu Dear Ms., Welcome to our practice. Your appointment AM/PM ( ) Dr. Gunhilde Buchsbaum ( ) Dr. Paula Doyle ( ) Dr. Erin Duecy ( ) Dr. Lioudmila Lipetskaia ( ) Pam Wigent, NP The Medical Team - We are committed to the education of both our patients and the medical community and are proud to be a part of the University of Rochester Medical Faculty. Members of our team our doctors, nurse practitioners, fellows and senior residents, routinely participate in the care provided in our office. BEFORE YOUR VISIT Complete the included 2-day voiding journal well in advance of your scheduled visit. This document is necessary for your evaluation, even if you do not have symptoms of urinary leakage. Failure to complete this diary may result in additional visits and may delay treatment. Please do NOT empty your bladder within 1 hour of your appointment. Please bring the entire packet to your visit including your insurance card (DO NOT MAIL). Insurance - We accept most major insurances in the Rochester area, but do not participate with all insurances. Please contact your referring physician and/or insurance company to determine if a referral is required. Your deductible or co-payment fee is determined by your insurance company. We accept exact amount cash, checks, MasterCard and Visa, and Discover. Late Arrivals/Cancellations -If you arrive late for your appointment, you may be rescheduled. We respectfully ask a minimum 24-hour prior notice to cancel an appointment. If you cannot keep an appointment, please notify the office as soon as possible to allow another patient to be seen. Should you not notify us of a cancellation, a $50 charge may be applied. Directions to Our Office: A map with written directions is enclosed. PLEASE allow extra time if you are unsure of our location. Please feel free to contact us ahead of time if you have any questions about our location. LATE ARRIVALS MAY RESULT IN RESCHEDULING. We look forward to participating in your medical care. Please contact our office if you have any questions or concerns.

2 Division of Urogynecology and Reconstructive Pelvic Surgery Pelvic Health and Continence Specialties 500 Red Creek Dr. Suite 120 Rochester, New York Gunhilde M. Buchsbaum, MD Erin E. Duecy, MD Paula J. Doyle, MD Lioudmila, V. Lipetskaia, MD Pam J. Wigent, NP Research Information Research helps improve health care. In collaboration with our patients, we strive for superior medical care supported by scientific study. During the course of your care, you may be approached to participate in a research study. You will have the opportunity to accept or to decline participation in any of these studies at any time. Signing this form will ONLY give us permission to contact you about opportunities. We may do so either in clinic, by mail, or over the phone. Thank you for helping to improve medical knowledge and patient care. Patient name (please print) Patient s Date of Birth Patient s Signature Date Signed

3 VOIDING DIARY INSTRUCTIONS Please use the enclosed form to keep a record of measurement of your fluid intake, your voids (urination), and any episodes of urine leakage for 2 days. Read the directions carefully and complete the diary before your appointment. If you would like to purchase a container (Specipan) that fits inside your toilet to help measure your voids, you may contact Westside Medical Supply in Gates/Greece at (585) or Fonte s Surgical Supply in Irondequoit at (585) The cost is typically $ $3.00. Otherwise, you may use any standard measuring cup. You may measure your fluid intake and void amounts in cups, ounces, or milliliters (ml or cc), but please indicate which units you are using. Choose a 48-hour (2 days together, Example: Monday-Tuesday) period that is convenient for you. You need to start from the first void of when you get up in the morning and continue for the entire 48 hours, including nighttime. TIME VOIDED LEAKED ACTIVITY URGE PRESENT TYPE OF FLUID Record the time of every void, leak, or drink. Measure the amount of urine voided. Estimate the amount of urine leaked: drops, wet, soaked, etc. Record what you were doing when you had leakage of urine. For example: laughing, doing dishes, coughing, sitting, walking to bathroom, etc. If you felt the urge to void before you lost urine, record yes. If you did not, record no. Measure and record the amount and type of all liquids you drank. EXAMPLE TIME VOIDED LEAKED 7:00 AM 3 ounces Drops 7:30 AM ACTIVITY AT TIME OF LEAK Walking to bathroom 8:00 AM Wet Coughing No URGE PRESENT? YES/NO Yes FLUID INTAKE TYPE/ Coffee 8 ounces

4 NAME MEDICATIONS & SUPPLEMENTS: Please list all medications you are currently taking (including any over-the-counter medications, vitamins, or herbal supplements/home remedies). Include dosage and how often you take it. If you need more room, please list all medications on a separate sheet of paper and attach it to this packet. Medication Name Dosage How Often Preferred Pharmacy: Phone: Address/Location: ALLERGIES/MEDICATION REACTIONS: Are you allergic to latex? no yes If yes, please list reaction: Please list all medication allergies or reactions below, including the type of reaction experienced. If you need more room, please list all medication and reactions on a separate sheet and attach it to this packet. Medication Name Type of Reaction (hives/rash, itching, shortness of breath, nausea, etc.)

5 VODING DIARY DO NOT USE PENCIL PT NAME: DATE: TIME VOIDED LEAKED ACTIVITY AT TIME OF LEAK URGE PRESENT? YES/NO FLUID INTAKE TYPE/

6 VODING DIARY DO NOT USE PENCIL PT NAME: DATE: TIME VOIDED LEAKED ACTIVITY AT TIME OF LEAK URGE PRESENT? YES/NO FLUID INTAKE TYPE/

7 VODING DIARY DO NOT USE PENCIL PT NAME: DATE: TIME VOIDED LEAKED ACTIVITY AT TIME OF LEAK URGE PRESENT? YES/NO FLUID INTAKE TYPE/

8 PLACE PATIENT LABEL HERE UROGYNECOLOGY: PATIENT INTAKE FROM Primary Care MD GYN MD Referred by: ( ) Primary ( ) GYN ( ) Other Why are you coming for this evaluation? How long have you had this problem? What treatments have you tried? MEDICAL HISTORY: Number of: Pregnancies Vaginal Deliveries C-Sections GU ENDO CARDIAC HEME RESP Medical Problems Asthma Chronic Cough Chronic Obstructive Pulmonary Disease (COPD) Blood clot in leg or arm Blood clot in lung Blood Disorder circle specific problem chronic anemia, von Willebrand s disease, sickle cell trait/disease, thalassemia, hemophilia Heart Disease circle specific problem heart attack, coronary artery disease, angina, congestive heart failure, stent placement Heart Condition - circle specific problem abnormal beats or rhythm, murmur, pacemaker, artificial valves High Blood Pressure Stroke Transient Ischemic Attack (TIA) Diabetes - circle specific problem diet controlled, oral medications, insulin shots Thyroid Disease - circle one: hypo- or hyper- Kidney Disease - circle specific problem polycystic kidneys, renal insufficiency, renal failure (on dialysis), anatomic abnormality of kidneys or ureters Kidney Stones Recurrent Bladder Infections (UTI) - > 3/year Interstitial Cystitis Abnormal Pap Smear year: Please check one: Current Past problem problem Never a problem

9 PSYCH NEURO MSK GI Medical Problems Irritable Bowel Syndrome circle type diarrhea-predominant, constipationpredominant, mixed Chronic constipation Acid Reflux/Chronic Heartburn Liver Disease type Arthritis circle type osteo-, rheumatoid, psoriatic Fibromyalgia Epilepsy/Seizure Disorder Parkinson s Disease Multiple Sclerosis Depression Anxiety Cognitive Impairment or Dementia Glaucoma circle type: wide/open or narrow/closed Chronic Pain Location: Please check one: Current Past problem problem Never a problem OTHER Cancer circle type breast, cervical, endometrial/uterine, ovarian, bladder, kidney, other: Other: Other: SURGICAL HISTORY: Please list all past surgeries. If you need more room, please list all surgeries on a separate sheet and attach to this packet. Hysterectomy? no yes year: route: abdominal incision laparoscopic vaginal Removal of Ovaries? no yes: both right left Year Type of Surgery Surgeon/Hospital Complication

10 SOCIAL HISTORY: Do you.. No Past Use Yes Details Use tobacco? Use recreational drugs? Drink alcohol? Quit date: Quit date: Quit date: # packs per day: # years of use: Type: How often? Type: # drinks per week: Occupation: retired disabled Are you currently sexually active? no yes Have you been sexually abused? no yes: as a child as an adult currently Have you been physically abused? no yes: as a child as an adult currently Are you a primary caregiver to someone? no yes: relationship: Marital/Relationship status: married single divorced separated other: Who do you live with? alone spouse/significant other family other: What is your usual level of physical activity? very active & exercise regularly active a little active not active What is your current mobility level? walk without any problems or assistive devices need a cane or walker need help getting on an exam table use a wheelchair

11 FAMILY HISTORY: check here if you are adopted and do not have this information. Has anyone in your family (blood relative) been diagnosed with any of the following? Medical Problem Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Father Mother Brother Sister Other Bleeding or clotting problem (von Willebrands, hemophilia, platelet disorder, Factor V Leiden) Breast Cancer Colon or Rectal Cancer Diabetes Endometrial or Uterine Cancer Heart Attack Heart Disease Ovarian Cancer Stroke or TIA Other: Other: REVIEW OF SYMPTOMS: Circle and of the following symptoms you are currently experiencing: Constitutional Skin HENT Eyes Cardiovascular Respiratory GI MSK Endo/Heme/IMM Neuro Psych fever chills weight loss weight gain malaise/fatigue sweating night sweats weakness rash itching headaches hearing loss ringing in ears ear pain ear discharge nosebleeds congestion sore throat blurry vision double vision pain with light in eyes eye pain eye discharge eye redness chest pain palpitations shortness of breath with lying down leg pain with walking leg swelling waking up at night short of breath cough coughing up blood productive cough shortness of breath wheezing heartburn nausea/vomiting abdominal pain diarrhea constipation blood in stool dark, tarry stools bloating muscle pain/aches neck pain back pain joint pain frequent falls easy bruising/bleeding allergies feeling too thirsty dizziness tingling/numbness tremor change in sensation change in speech weakness in one arm or leg seizures passing out/fainting depression suicidal ideas substance abuse hallucinations anxiety insomnia memory loss

12 UROGYNECOLOGY: Were you treated for 3 or more bladder infections in the last year? no yes Do you have difficulty emptying your bladder? no yes Do you have pain when you urinate? no yes How many time do you get up to empty your bladder at night? 0/rarely or more How often do you have bowel movements? daily every other day 1-2 times a week less than once per week Do you leak stool? no yes: liquid stool loose stool soft stool formed stool If you experience URINARY INCONTINENCE, do you: Usually have an urge to urinate before you leak urine? no yes Leak urine or rush to the bathroom when you see/feel/hear running water? no yes Leak urine or rush to the bathroom when you approach your home after being out? no yes Leak urine when you cough, sneeze, laugh, or exercise? no yes Wet the bed when you are completely asleep? no yes Feel like you leak constantly? no yes Wear pads to protect your clothing from leakage of urine? no yes If you wear pads, what kind? pantiliner thin pad thick pad diaper

13 Pelvic Floor Disability Index (PFDI-20) Instructions: Please answer all of the questions on the following survey. These questions will ask you if you have certain bowel, bladder, or pelvic symptoms and, if you do, how much they bother you. Answer these by circling the appropriate number. While answering these questions, please consider your symptoms over the last 3 months. The PFDI-20 has 20 items and 3 scales of your symptoms. All items use the following format with a responsive scale from 0 to 4. Symptom scale: 0 = not present 1 = not at all 2 = somewhat 3 = moderately 4 = quite a bit Pelvic Organ Prolapse Distress Inventory (POPDI-6) Do you NO YES 1. Usually experience pressure in the lower abdomen? Usually experience heaviness or dullness in the pelvic area? Usually have a bulge or something falling out that you can see or feel in your vaginal area? Ever have to push on the vagina or around the rectum to have or complete a bowel movement? Usually experience a feeling of incomplete bladder emptying? Ever have to push up on a bulge in the vaginal area with your fingers to start or complete urination? Colorectal-Anal Distress Inventory 8 (CRAD-8) Do you NO YES 7. Feel you need to strain too hard to have a bowel movement? Feel you have not completely emptied your bowels at the end of a bowel movement? Usually lose stool beyond your control if your stool is well formed? Usually lose stool beyond your control if your stool is loose? Usually lose gas from the rectum beyond your control? Usually have pain when you lose your stool? Experience a strong sense of urgency and have to rush to the bathroom to have a bowel movement? Does part of your bowel ever pass through the rectum and bulge outside during or after a bowel movement? Urinary Distress Inventory 6 (UDI-6) Do you NO YES 15. Usually experience frequent urination? Usually experience urine leakage associated with a feeling of urgency, that is, a strong sensation of needing to go to the bathroom? 17. Usually experience urine leakage related to coughing, sneezing, or laughing? Usually experience small amounts of urine leakage (that is, drops)? Usually experience pain or discomfort in the lower abdomen or genital region? Scoring the PFDI-20 Scale Scores: Obtain the mean value of all the answered items within the corresponding scale (possible value 0 to 4), then multiply by 25 to obtain the scale score (range 0 to 100). Missing items are dealt with by using the mean from answered items only.