CRRS NEW PATIENT QUESTIONNAIRE
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- Millicent Sparks
- 5 years ago
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1 CRRS EW PATIET QUESTIOAIRE ame: DOB: Date: Height: Weight: Modified International Pelvic Pain Society Questionnaire (Scale: 0-no pain, 10-worst pain imaginable) Overall pain /A Pain (not cramps) before period /A Ovulation (midcycle) pain /A Pain just before period /A Period cramps /A Pain after period is over /A Pain in groin when lifting /A Pain with insertion during intercourse /A Deep pain with intercourse /A Pelvic pain lasting for hours/days /A after intercourse Pain when bladder /A is full Pain with urination /A Pain right after /A urination Pain at the flank / /A Kidney Lower back pain /A Muscle or joint pain /A Pain with bowel /A movement Severity of /A constipation Severity of /A diarrhea Severity of bloating /A Severity of intestinal /A cramping Pain with sitting /A Pain on neck / shoulders Pain underneath ribs /A /A
2 More Information about your pain What type of treatments or providers have you tried in the past for your pain? (Please check all that apply) Acupuncture Anesthesiologist Anti-seizure medications Biofeedback Botox injection Contraceptive pills / ring / patch Danazol (Danocrine) Depo-provera Gastroenterologist Gynecologist Family Practitioner Herbal Medicine Homeopathic Medicine Lupron, Synarel, Zoladex, e.t.c Massage Meditation arcotics aturopathic medication erve blocks eurosurgeon on-prescription medicine utrition / Diet Physical Therapy Psychological Counsellor Psychiatrist Rheumatologist Skin magnets Surgery TES unit Trigger point injections Urologist Letrozole (Femara) Pain Maps Please shade all areas of pain. Indicate with a star the area where you experience the most pain
3 Infertility Questions (skip this section if you are OT currently trying to conceive) How many months have you and your husband tried to conceive? Are you working with any health care provider(s)? o (We strongly recommend that you work with one) es (Please provide details) ame Specialty Phone/Fax Records mailed ame Specialty Phone/Fax Records mailed Previous Fertility-Related Investigations: (Please check if you have had any of the following and provide results from the most recent testing) Test Month/ear Results and Comments Ultrasound of uterus and ovaries Ultrasound of the ovaries to look at ovulation (follicle tracking) Hysterosalpingogram (Xray assessment of the uterus and fallopian tubes) Hysteroscopy (camera visualization of the uterine cavity) Endometrial biopsy D&C (scraping of the lining of the womb) Post-coital test (looking at sperm taken from your cervix after intercourse) Day 3 or early cycle blood test Day 21 or late cycle blood test (progesterone/ovulation) Other blood tests or investigations Previous Fertility-Related Diagnosis (Please check if you have, or have had, any of the following) Unexplained Infertility Recurrent Miscarriage Endometriosis Polycystic Ovaries (PCOS / PCOD) Low Progesterone Low Estrogen ot Ovulating Leutenized Unruptured Follicle (LUF) Fibroids in or on Uterus Pelvic Adhesions / Scar Tissue Abnormal Ovulation Hostile / Limited Cervical Mucus Polyps in Uterus Blocked / Damage Tubes Male Factor Infertility Adhesions in Uterus (Asherman) Previous Fertility-Related Surgery (Please check if you have had any of the following and provide the year(s) of the surgery) Superficial treatment for endometriosis. ear: Surgery for Uterine Polyps. ear: Ovarian surgery for Polycystic Ovaries. ear: Excisional treatment for endometriosis. ear: Fallopian tube reconstruction. ear: Surgery for Fibroids (Myomectomy). ear:
4 Gynecological and Obstetrical History Age of first menses: Age pelvic pain began: Are you postmenopausal: Are you trying to conceive: What is your period like? Light Moderate Heavy Period every days Regular Irregular o. of pregnancies: o. of live births: o. vaginal deliveries: o. of cesarean section: o. of living children: o. of miscarriages: o. elective abortions : o. ectopic: Complications around delivery? Vacuum/Forceps Medication for bleeding Vaginal laceration Postpartum Hemorrhage Are you using any form of hormonal birth control currently? o es (what type) Did you have trouble getting pregnant? /A o es How long did you try before getting pregnant? months How did you achieve pregnancy? Spontaneous Ovulation Induction IUI IVF Other: Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period? es o Date of your last PAP and results: Have you ever had these procedure (If so, please provide year)? Colposcopy LEEP Cone Have you ever been diagnosed with sexually transmitted infection or pelvic inflammatory disease? es o Current Health Care Providers (physicians and non-physicians) ame Specialty Phone and fax number Records attached? Current Pain Management Doctor: Medical History (Please check if you have, or have had, any of the following) Anemia Arthritis Asthma Bladder disease Cancer Anxiety Chlamydia Chron s / Ulcerative Colitis Congenital Heart Disease Depression Deep Vein Thrombosis (DVT) Emphysema / COPD Epilepsy / Seizures Fibromyalgia Diabetes Glaucoma Gonorrhea Heart Attack (MI) Heart Murmur / Valve disease Heart Failure Hepatitis Heartburn / Reflux (GERD) Herpes HIV / AIDS HPV Hypertension Irritable Bowel Syndrome Interstitial Cystitis Kidney Disease / Renal Failure Kidney / Ureteral Stones Migraine Headaches Osteoporosis / Osteopenia Pulmonary Embolus (PE) Sickle Cell Disease / Trait Hemophilia Stroke Syphilis Thyroid Disease Trichomonas Tuberculosis Pneumothorax Hemoptysis (Cough up Blood) Pancreatitis Gallbladder disease / stones Have you ever had a blood transfusion? o es Do you have any objection to blood transfusion? o es
5 Surgeries (please list all your surgeries in chronological order starting with your first procedure) Month / ear Procedure and findings How much help did the surgery provide? Surgical Report attached? Surgical History (Please check if you have had any of the following) Single Ovary Removed Both Ovaries Removed Ovarian Cyst Removed Gallbladder Removed Cesarean Section Dilation and Curettage (D&C) Heart Surgery Hernia Repair Hysteroscopy Breast Surgery Appendectomy Cervical Cerclage Tubal Ligation Fallopian Tube(s) Surgery Fallopian Tube(s) Removed Tonsillectomy / Adenoidectomy Laparotomy (Open Surgery) Laparoscopy (Includes Robotic) Uterus removed (Hysterectomy) Vulvar Surgery / Biopsy Any prior complications to anesthesia? o es (please specify) Review of Systems (Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain) Skin Chest/Heart Recent changes in: Head/eck Back Weight Ears Intestinal Energy level ose Bladder Ability to sleep Throat Bowel Appetite: Lungs Circulation
6 Medical History List your prescribed drugs ame the drug Strength Frequency Reason List your over-the-counter drugs, such as vitamins and supplements ame the drug Strength Frequency Reason Allergies to medications ame the Drug Reaction ou Had Health Habits Alcohol What type of alcohol do you drink? How many drinks per week? Tobacco If yes, how many packs of cigarettes per day? For how many years? Or years quit? Drugs Do you currently use recreational / street drugs? Have you ever given yourself street drugs with a needle? Comments: PLEASE PROVIDE OUR ARRATIVE SUMMAR O A SEPARATE SHEET OF PAPER Copyright The CRRS - The Center for Restorative Reproductive Surgery
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Patient Name Date of Birth Thank you for choosing Southern Cancer Center for your care. To help us best prepare for your appointment, please complete this form and bring it to your appointment. If you
Questionnaire. General Questions: DOB: Current address: Daytime phone #: Evening phone #: Current occupation:
Submit your completed questionnaire to the Women s Center Coordinator Fax: 713.798.2689 or Mail: Women s Center for Comprehensive Care Baylor Clinic 6620 Main Street, Ste. 1225 Houston, TX 77030 Questions?
How much do you know about illnesses or health problems for your parents, grandparents, brothers, sisters, and/or children? 1 A lot Some None at all
Family Health History Please answer each question as honestly as possible. There are no right or wrong answers to nay of the questions. It is important that you answer as many questions as you can. We
New Patient History Form (Age 18 and over)
New Patient History Form (Age 18 and over) Obstetrics & Gynecology Name Age Date first middle last Occupation Marital Status: c Single c Married c Divorced c Widowed Referred to our office by: What is
Name Age Date. Address Phone. Name of Physician. Address Street Address City State Zip Code
Name Age Date Address Phone What is the reason for your visit today? Where have you been receiving your medical care? Name of Physician Address Street Address City State Zip Code PAST MEDICAL HISTORY:
Patient Name Date of Birth Age. Other phone ( ) . Other
GASTROINTESTINAL & MINIMALLY INVASIVE SURGERY HEALTH HISTORY QUESTIONNAIRE Date Patient Name _ Date of Birth Age Daytime phone ( ) Other phone ( ) Email How did you hear about us? My doctor Yellow pages