Female Pelvic Medicine & Reconstructive Surgery Beth Israel Deaconess Medical Center (BIDMC)
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- April McDonald
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1 Female Pelvic Medicine & Reconstructive Surgery Beth Israel Deaconess Medical Center (BIDMC) Name: Age: Reason for visit/referral: Are you referred for or interested in surgery? Yes No Maybe Referring physician: Specialty: _ Referring physician address: Primary Care Physician: PCP physician address: Past Medical History Do you currently have, or have you had in the past, any of the following conditions? Glaucoma Lung disease Heart attack High blood pressure Congestive heart failure Blood clots Bleeding disorders Cancer Kidney stones Hepatitis/Liver Disease Seizures/Epilepsy Multiple Sclerosis Stroke Parkinson s disease Spinal Bifida Trauma to spinal cord Brain injury Disc herniation Low back pain Diabetes Autoimmune disease Lupus Thyroid disease Depression Anxiety Fibromyalgia Osteoporosis What other medical problems (which are not listed above) do you suffer from? Past Surgical History Please list the surgeries you have had: Year Past GYN History Date of last period: Date of last pap smear test: / / Your Periods: are regular or irregular Have you ever had an abnormal pap test?: Past Obstetrical History Total # pregnancies: # of Vaginal Deliveries: # of Cesarean Section: # of Living Children: # of Ectopics: # of Abortions: Birth weight of largest baby delivered vaginally: Did you ever have a forceps-assisted vagina delivery? Did you ever have a vacuum-assisted vaginal delivery?
2 Family History Has anyone in your family had any of the following illnesses? Condition Relation (eg. father) Condition Relation (eg. father) Heart attack Colon Cancer High blood pressure Uterine Cancer Stroke Ovarian cancer Blood clots Breast Cancer Bleeding disorders What other medical problems run in the family? Social History Marital status: single married living with partner divorced other: Current or most recent job: Do you smoke? Have you ever smoked? How many cigarettes per day? For how many years? How many alcoholic beverages do you drink per week? Do you take illicit drugs? Which ones? Have you ever been sexually abused? Allergies Medication Allergies: Latex Allergic: Other Allergies: Medications If your medications are not part of our electronic medical records system, please list all your current medications (include herbal and non-prescription medications): Medication Dose Review of Systems Do you have any of the following symptoms? Constitutional Fever Eyes Blurry vision Glasses/contact lens Ear, nose and throat Hearing problems Cardiovascular Chest pain Difficulty breathing on with activity Leg swelling and/or feet Heart murmurs Heart palpitations Respiratory Shortness of breath Chronic cough Gastrointestinal Constipation Abdominal pain Bloody stools Frequent diarrhea Genitourinary Abnormal vaginal bleeding Musculoskeletal Muscle weakness Low back pain Neurological Numbness Headaches Mental Health Memory Loss Endocrine Hot flashes Abnormal thirst Hematologic/Lymphatic Excessive bruising Cuts that do not stop bleeding
3 If you have a problem with urination, prolapse, and/or fecal incontinence, please answer the following questions. Please circle the appropriate answer. URINARY INCONTINENCE 1. Do you leak urine? Yes 2. If yes, how long have you leaked urine? Months / years The urine leakage is getting: Same Better Worse 3. If you do leak urine, how many times a day do you leak? 4. Do you leak urine with cough, sneeze, lifting, laugh, or exercise? Often Sometimes Rarely 5. How often, on average, do you urinate during the day? Every 0.5 hour 1hr 1.5 hrs 2 hrs 2.5 hrs 3 hrs or more 7. How often do you get up at night to void? 4 >=5 8. When you have an urge to void, do you leak urine before making it to the toilet? 9. Do you receive little warning and suddenly find that you are losing urine beyond your control? 10. Are you aware of when you have urine leakage? 11. Do you lose urine continuously? 12. Right after you have voided, do you have any further dribbling out of urine? 13. What kind of protection do you wear for leakage? None Pantyliner Mini-pad Maxi-pad 14. How often do you change your pad per day? What prior treatment( s) for urinary incontinence have you had? None Kegels Physical therapy Biofeedback Urethral injections Surgery Interstim Medications: Oxybutynin Detrol Ditropan Oxytrol Gelnique Enablex Vesicare Sanctura Imipramine Urecholine Toviaz Estrogen URINARY SYMPTOMS 16. How often do you get bladder infections? Never < l/year 1-2/year 3-4/year >= 5/year 17. Have you ever had kidney stones? 18. Have you ever had blood in the urine? 19. Do you have burning associated with voiding? 20. Do you have pain or pressure associated with voiding? 21. Do you feel like your bladder is empty after you have voided? 22. Do you have to strain to void? 23. Is your urine flow: normal intermittent hesitant slow 24. Do you need to push on your vagina, bladder, rectum to urinate or defecate? Never Incontinence Pad (Eg: Poise, Depends) 3 4 >=5 Electrical Stimulation Miragegron Other PROLAPSE 25. Do you have pressure, or a feeling of a 'bulge' or tissue dropping in the vagina? 26. What prior treatment have you had for pelvic organ prolapse? None Pessary Surgery GASTROINTESTINAL 27. Do you have problems with constipation? 28. Do you have difficulty with defecation/bowel movements? Often Sometimes Rarely 29. Do you lose stool involuntarily? Never SEXUALITY 30. Are you sexually active? 31. Does your problem with urination and/or prolapse interfere with intercourse? 32. With intercourse, do you have any of the following? Pain Numbness Vaginal dryness Inability to orgasm
4 NAME Are you referred for or interested in surgery? Yes No Maybe Pelvic Organ Prolapse Distress Inventory 6 (POPDl-6) Do you experience, and, if so, how much are You bothered by... Not at all Somewhat Moderately Quite a bit 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 the bulge in the vaginal area with your fingers to start or complete urination? Pelvic Floor Impact Questionnaire Instructions: Some women find that bladder, bowel, or vaginal symptoms affect their activities, relationships, and feeling. For each question place an X in the response that best describes how much you're activities, relationships, or feelings have been affected by your bladder, bowel, or vaginal symptoms or conditions over the last 3 months. Please make sure you mark an answer in all 3 columns for each question. How do symptoms or conditions relate to the following Usually affect your Bladder or Urine Bowel or Rectum Vagina or Pelvis 1. Ability to do household chores (cooking, housecleaning, laundry)? 2. Ability to do physical activities such as walking, swimming, or other exercise? 3. Entertainment activities such as going to a movie or concert? 4. Ability to travel by car or bus for a distance greater than 30 minutes away from home? 5. Participating in social activities outside your home> 6. Emotional health (nervousness, depression, etc)? 7. Feeling frustrated?
5 Urinary Incontinence Assessment in Older Adults UROGENITAL DISTRESS INVENTORY SHORT FORM (UDI-6) Please answer each question by checking the best response. While answering these questions, please consider your symptoms over the last 3 months. We realize that you may not be having problems in some of these areas, but please fill out this form as completely as possible. Do you experience, and if so how Not at all Slightly Moderately Greatly much are you bothered by Frequent urination Leakage related to feeling or urgency Leakage related to physical activity, coughing, or sneezing Small amounts of leakage (drops) Difficulty emptying bladder Pain or discomfort in lower abdominal or genital area INCONTINENCE IMPACT QUESTIONNAIRE-SHORT FORM (IIQ-7) Some people find that accidental urine loss may affect their activities, relationships, and feelings. The questions below refer to areas in your life that may have been influence or changed by your problem. For each question, circle the response that best describes how-much your activities, relationships, and feelings are being affected by urine leakage. Has urine leakage affected your Not at all Slightly Moderately Greatly 1. Ability to do household chores (cooking, housecleaning, laundry)? 2. Physical recreation such as walking, swimming, or other exercise? 3. Entertainment activities (movies, concerts, etc.)? 4. Ability to travel by car or bus more than 30 minutes from home 5. Participation in social activities outside your home? 6. Emotional health (nervousness, depression, etc.)? 7.Feeling frustrated Items 1 and 2 = physical activity; Items 3 and 4 = travel Item 5 = social/relationships; Items 6 and 7 = emotional health Scoring: Item responses are assigned values of 0 for "not at all," 1 for "slightly," 2 for "moderately," and 3 for "greatly." The average score of items responded to is calculated. The average, which ranges from 0 to 3, is multiplied by 33 1/3 to put scores on a scale of O to I 00. Reference: Uebersax, J.S., Wyman, J.F., Shumaker, SA., McClish, D.K.,Fantl, JA., & the Continence Prograrn for Women Research Group. (1995). Short forms to assess life quality and symptom distress for urinary incontinence in women: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Neurology and
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