Tel: (312) Women s Integrated Fax: (312) Pelvic Health Program. 1.0: Basic Information. Preferred Language:

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Transcription:

Tel: (312) 694-7337 Women s Integrated Fax: (312) 695-0156 Pelvic Health Program 1.0: Basic Information Date of Birth: / / Age: Home Address: Preferred Language: English Spanish Other: Email address: Preferred Contact Number: ( ) - Emergency Contact Emergency Contact Number: ( ) - Race: American Indian or Alaska Native Asian/Asian American Black or African American Native Hawaiian or other Pacific Islander White Other: Ethnicity: Hispanic or Latino t Hispanic or Latino Employment: Employed part-time Employed full-time Unemployed Retired Marital Status: Married/civil union Living with a partner Separated or divorced Widowed Single, never married Page 1 of 8

2.0: Today s Visit Referring Provider: Primary Care Physician: General Ob/Gyn: Address: Phone Number: ( ) - Fax Number: ( ) - Address: Phone Number: ( ) - Fax Number: ( ) - Address: Phone number: ( ) - Fax Number: ( ) - Please describe the nature of your current pelvic floor medical problem and include any treatments you have tried for this problem in the past. Women have different goals for their pelvic care. Please list your personal goals for treatment of your pelvic problems in order of importance. Please also rate the level of importance of achieving this treatment goal on a scale from 0 (not important to me) to 10 (very important to me). Ranking: 1. My personal goals for treatment are: Rating of level of achieving treatment goal 2. 3. 4. 5. Page 2 of 8

What is the main reason for your visit today? Please list any drug allergies: 3.0: Chief Complaint, Allergies & Medications Pharmacy: Address: Phone Number: ( ) - Please list any medications you are currently taking: Medication Name Start Date Prescribing Physician Page 3 of 8

History Form You may receive a phone call from a staff member in our practice to discuss this information before your appointment. 4.0: Medical History Please check any/all of the below medical problems that you have or have had in the past. Cardiovascular Coronary artery disease (I25.1) Previous myocardial infarction (heart attack) Congestive Heart Failure (I50.42) Heart murmur (R01.1) High blood pressure (I10) Peripheral vascular disease (I73.9) Atrial fibrillation (I48.91) High cholesterol (E78.5) Other: Neurological / Psychological: Parkinson s Disease (G20) Multiple Sclerosis (G35) Stroke or TIA (I69) Seizure disorder (G40) Depression (F32.9) Anxiety (F41.9) Insomnia (F51.01) Other: Endocrine: Hypothyroidism (E03.9) Hyperthyroidism (E05.90) Grave s Disease (E05.00) Type 1 Diabetes (E10.9) Type 2 Diabetes (E11.9) Other: Gastrointestinal: Irritable Bowel Syndrome (IBS) (K58.0) Stomach Ulcer (K25.9) Duodenal Ulcer (K26.0) Chron s Disease (K50.1) Ulcerative Colitis (K51.00) Esophageal reflux (K21.9) Liver disease Hepatitis A B C Cirrhosis (K74.6) Other: Respiratory: COPD / Emphysema (J44.9) Pneumonia (J18.1) Asthma (J45.20) Tuberculosis (A15.0) Sleep apnea (G47.33) Other: Musculoskeletal: Arthritis Osteoarthritis (M19.91) Rheumatoid arthritis (M05.9) Osteopenia (M85.80) Osteoporosis (M81.0) Other: Cancers, other medical problem (please specify): Page 4 of 8

5.0: Surgical History Have you had a hysterectomy? Have you had your ovaries removed? Yes, an abdominal hysterectomy Yes, a vaginal hysterectomy Yes, a laparoscopic/robotic hysterectomy Yes Please list any other surgeries you have had below: Date Surgeon: 6.0: Family History Have any of your first-degree relatives (parents, siblings, children) had any of the medical problems below? Problem: Breast cancer Uterine cancer Ovarian cancer Colon cancer Bleeding or clotting problems Leakage of urine Pelvic organ prolapse Family member: Page 5 of 8

7.0: Social History Do you or have you used tobacco? Check all that apply: Cigarettes Cigars Smokeless Tobacco Currently Formerly Never If you are a smoker, how many packs per day do you smoke? Do you drink alcohol? If you drink alcohol, how many drinks do you have per week? Have you used any recreational drugs (e.g. marijuana, narcotics, etc)? If you use recreational drugs, how many times do you use them per week? Do you exercise? If you currently exercise, what type of exercise do you do and how often? Are you sexually active? Yes If you are currently sexually active, please indicate your partner s gender. Male Female Both Are you satisfied with your sexual function? Yes If you are not satisfied with your sexual function, which problem(s) do you have? Decreased interest Pain with sex Decreased vaginal lubrication Problems with orgasm Decreased genital sensation Other: 8.0: Obstetrical and Gynecological History How many times have you been pregnant? How many children have you delivered? 0 1 2 3 4 5 6 7 8 9 10 How much did your largest infant weigh at birth? N/A How many of your deliveries were forceps assisted? How many were vacuum assisted? How many were cesarean sections? Page 6 of 8

When was your last Date rmal Results Abnormal PAP smear? Mammogram? Colonoscopy? Menstrual Period? Are you post-menopausal? Yes If you are post-menopausal, have you had any bleeding since menopause? Yes Do you or have you taken hormone pills (birth control, hormone replacement)? Yes (please specify): Have you ever had an abnormal PAP smear? Yes If you have had an abnormal pap smear, did you have any of the following procedures performed? LEEP Cone biopsy Cryoablation ( freezing ) Laser ablation Colposcopy t applicable Page 7 of 8

9.0: Review of Systems Please check any or all items that you are currently experiencing. Well Acutely unwell Chronically unwell How do you feel today? Eyes, Ears, se & Throat Fever Tremors Night sweats Fatigue Constitutional Skin/Breast Weight loss Weight gain Pain Glaucoma Hearing Loss se Bleeds Sinus Problems Bleeding gums Itching Rash Dryness Flaky Breast pain Breast mass/lump Nipple discharge Gastrointestinal Cardiac Nausea Vomiting Diarrhea Soreness of mouth Difficulty swallowing Poor appetite Constipation Abdominal Pain Blood in stool Chest pain Palpitation Shortness of breath Feet swelling Coughing Coughing blood Wheezing/asthma Vaginal dryness Vaginal soreness Pulmonary/Respiratory Gynecological Psychological Genitourinary Painful or difficult urination/dysuria Increased frequency of urination Urinary incontinence Headache Double vision/diplopia Seizures Lightheaded/dizzy Neurological Musculoskeletal Tremors Numbness/tingling Anxiety/Depression Insomnia Memory loss/confusion Fatigue/weakness Muscle soreness/pain Joint pain Back pain Page 8 of 8

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