Vulvar and Vaginal Disorders Questionnaire

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Transcription:

1 Your Name: Vulvar and Vaginal Disorders Questionnaire Referring provider: To whom should we send a report about this visit: My physician: Don t send anyone a report Address/Phone: Ethnicity (circle): Caucasian (white) Hispanic African American Pacific Islander Asian Other Reason for Visit: In your own words, describe the vulvar or vaginal symptoms (discomfort) you are having: include when the symptoms started, what has been done about them, and what has worked or not worked SYMPTOMS Which vulvar/vaginal symptoms bother you most: (circle all that apply) Itching Burning Irritation Rawness Soreness Sharp pain Dull pain Tearing/ripping pain Pain with sex Inability to have intercourse Change in normal skin color Change in normal skin texture Vaginal discharge Abnormal vaginal bleeding Which type of symptom is the most bothersome (Circle one)? Vaginal discharge Itching Burning Pain in general Pain with sex Dryness Other:

2 Are your symptoms primarily on the outside lips (vulva), inner lips (labia) or inside (vagina)? Vulva Labia Vagina A combination If possible, please mark on the diagram where you feel your symptoms: What things seem to make your symptoms worse? Do any of the things below make your symptoms worse (circle all that apply): Lying down Sitting for long periods of time Exercise Sex Tight clothes Nighttime What things seem to make your symptoms better? Are your symptoms related to your period? If so, how? How often do you have symptoms (please circle one)? Daily Several times a week Once a week Several times a month Only with sex other: Does the severity of your symptoms change day to day? If so, how? Are you currently sexually active? Yes No If not, is this upsetting to you? Yes No Are your sexual partners. Male Female Both/Either Do your symptoms interfere with your sex life? Yes No Please circle one of the following: Sex is Never / Sometimes / Always painful. Circle any statements that are true for you: I just don t want to have sex I want to have sex, but can t because of the pain Sex has never been enjoyable for me I avoid intimacy or relationships because of my symptoms I don t want to have sex because I am embarrassed by my symptoms I don t want to have sex because it is too painful My symptoms cause significant problems in my sexual relationship Relationship Status (circle any that apply) Single Dating Living with Partner Married Divorced/Separated Widowed Other Have you ever been in a relationship in which you were threatened, controlled, physical hurt, sexually assaulted or made to feel afraid? No Yes

Hormones Oral Pain Medicatio n Topical Steroids BV Medication s Yeast medications 3 Have you used any of the following products? If so, when, and did it help? Over the counter yeast cream When How many times? Did it help? Fluconazole (Diflucan) Mycolog/Lotrisone Other prescription yeast cream Flagyl (pill) Metrogel Vaginal clindamycin Clobetasol (Temovate) Hydrocortisone Amitryptiline/Nortryptiline Gabapentin/Lyrica Vagifem Estring Estrogen vaginal cream Other Topical gabapentin (compounded) Topical lidocaine Vaginal valium Other Have you ever done pelvic floor physical therapy? Yes helped Yes didn t help No Have you ever had a trigger point injection? Yes helped Yes didn t help No Have you ever been treated with vaginal laser? Yes helped Yes didn t help No Have you ever had a vulvar biopsy? Yes No If yes, when and what did it show? Have you used any of the following to treat your vaginal symptoms? (Circle all that apply) Oral probiotics Oral garlic Oral yogurt Witch hazel Vaginal probiotics Douches Vaginal yogurt Hydrogen peroxide Vaginal garlic Tea tree oil Boric acid Gold Bond powder

GYNECOLOGIC HISTORY Have you ever been diagnosed with any of the following? (circle all that apply) Yeast Chlamydia Genital Herpes PID (pelvic inflammatory disease) Bacterial vaginosis Gonorrhea Genital warts/hpv Trichomonas Syphilis HIV (AIDS) Have you ever been diagnosed with any of the following? (circle all that apply) Uterine fibroids Ovarian cysts PCOS Endometriosis Uterine polyps Cervical polyps Bartholin s cyst/abscess Menstrual History: Are you menopausal? Yes No (if yes, how old were you when you stopped periods? ) 4 Menopause: (If you are not menopausal, skip to the next section) Do you use any hormonal treatments? No Yes, (what kind) Do you have any of the following? Hot flashes Vaginal dryness Night sweats Menstrual periods: Are your periods regular? Yes No, irregular No, absent because of medication or IUD No, other If other, please describe: Do you have any of the following? (circle) Heavy periods Painful periods Bleeding between periods When was your last period? What form of birth control, if any, are you using currently? (please circle all that apply) Diaphram/cervical cap Condom/spermicide Depo Provera Tubal Ligation Oral contraceptive (pills) Contraceptive patch Contraceptive ring Implant (Nexplanon) IUD - Copper IUD - hormonal Vasectomy Rhythm method Withdrawal Abstinence None Pap Smear History: Date of last pap: Was it normal? Yes No Not sure Have you ever had an abnormal pap smear? Yes No If so, when? How was it managed (circle)? Repeat Pap Colposcopy & Biopsy LEEP Cone biopsy Other OBSTETRIC HISTORY Number Total pregnancies Vaginal deliveries Cesarean deliveries Miscarriages Abortions Living children Are you planning a pregnancy in the next year? Yes No

5 MEDICAL HISTORY (Please circle any condition you have now or have had in the past) Asthma or lung problems Ulcerative colitis Migraines Lichen planus Irritable bowel syndrome Blood clots Lichen sclerosus Crohn s Disease Blood transfusion Heart Disease Stomach ulcers, reflux, GERD Fibromyalgia High Cholesterol Seasonal allergies Sjogren s High blood pressure Lupus Interstitial cystitis Diabetes Thyroid disorder Psoriasis Cancer Liver disease Eczema Chronic fatigue syndrome Multiple sclerosis Other: Anxiety Depression Surgical History: (please list all your prior surgeries, hospitalizations and dates) Have you had any of these additional symptoms/problems this week? (circle all that apply): Leaking urine with cough or sneeze Abdominal pain Itchy skin (not on vulva) Leaking urine on the way to bathroom Rectal bleeding Eczema Painful urination Difficulty emptying bladder Up at night frequently to pee Numbness in hands or feet Burning/tingling in hands or feet Dizziness Constipation Diarrhea Back or hip pain Joint Pain Chest Pain Fevers/Chills Mouth Ulcers Itchy or dry Eyes Dry mouth Problems Sleeping Trouble Breathing Cough Over the last 2 weeks, how often have you been bothered by the following problems? (circle): Not at All Several Days More than Half the Days (PHQ-4) Nearly Every Day 1. Feeling Nervous, anxious or on edge 0 1 2 3 2. Not being able to stop or control worrying 0 1 2 3 3. Little interest of pleasure in doing things 0 1 2 3 4. Feeling down, depressed or hopeless 0 1 2 3

6 OTHER INFORMATION: Do you work outside the home? Yes No If yes, what is your occupation Are you currently using tobacco (smoking, chewing, electronic cigarette/vaping)? No Yes How many alcoholic drinks do you have in an average week? (circle) None 0-2 3-6 7-10 >10 Have you used an illegal drug or prescription medication for nonmedical reasons in the last year? No Yes How often do you exercise? (circle) Never 1-2 times/week 3-5 times/week Daily If not exercising, why not? What questions would you like answered at this visit? What are you hoping for from this visit? Thank you very much for taking the time to complete this questionnaire!

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