History of Present Illness Please answer the following questions

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Last Name First Name Date of Birth: / / What is the main reason for your visit today? Social Security Number: History of Present Illness Please answer the following questions Bladder Cancer Urinary Tract Infections Hematuria (Blood in Urine) Renal Cyst/ Mass Kidney Stones Urinary Frequency Urinary Incontinence Other: Which symptoms best describe you? Check all that apply. Frequent Urination day, night, or both Sudden or strong urge to urinate Leakage with little or no warning----sometimes unable to make it to the bathroom in time Unable to completely empty the bladder-----feels like there is more even after going to the bathroom Accidental leakage with physical activity---exercising, sneezing, or coughing Bladder or pelvic pain Problems with bowel function (if checked, please select symptom below) Accidental loss or leakage of stool Constipation Other No Bladder or bowel problems How long have you had these symptoms? Have you tried medications to help your bladder symptoms? Yes No If yes, how many different medications have you tried? On a scale from 0 to 10, with 0 being no symptom relief and 10 being complete symptom relief, how much symptom relief have these medications provided for you? Circle a number 0 1 2 3 4 5 6 7 8 9 10 No Complete Relief Symptom Relief Are you still taking any of these medications? Yes No If no, why have you stopped taking them? Did not work as well as expected Side effects Expense Interaction with other medications Other If side effects or other checked, please explain: Behavior modifications tried? (I.e., reduced fluid intake, caffeine reduction, Kegel exercises, physical therapy, or lifestyle changes) On a scale from 0 to 10, with 0 being no frustration at all and 10 being extremely frustrated, what is your level of frustration with your bladder control symptoms? Circle a number 0 1 2 3 4 5 6 7 8 9 10 Not Extremely Frustrated Frustrated 1

Urogenital Distress Inventory Short Form (UDI-6) Please answer each question by checking the best response. While answering these questions, please consider your symptom 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 much are you Not at all Slightly Moderately Greatly bothered by Frequent Urination 0 1 2 3 Leakage related to feeling of urgency 0 1 2 3 Leakage related to physical activity, coughing, or sneezing 0 1 2 3 Small amounts of leakage (drops) 0 1 2 3 Difficulty emptying bladder 0 1 2 3 Pain or discomfort in lower abdominal or genital area 0 1 2 3 INCONTINENCE IMPACT QUESTIONAIRE-SHORT FORM (IIQ-7) Some people find accidental urine loss may affect their activities, relationships, and feelings. The questions below refer to areas in your life that may have been influenced 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)? 0 1 2 3 2. Physical recreation such as walking, swimming, or other exercise? 0 1 2 3 3. Entertainment activities (movies, concerts, etc.)? 0 1 2 3 4. Ability to travel by car or bus more than 30 minutes from home? 0 1 2 3 5. Participation in social activities outside your home? 0 1 2 3 6. Emotional health (nervousness, depression, etc.)? 0 1 2 3 7. Feeling frustrated? 0 1 2 3 Items 1 and 2 = physical activity; Items 3 and 4 = travel Items 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 0 to 3, is multiplied by 33 1/3 to put scores on a scale of 0 to 100. Reference: Uebersax, J.S., Wyman, J.F., Shumaker, S.A, McClish, D.K, Fantl, J.A., & the Continence Program for Women Research Group. (19950. 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 Urodynamics, 14(2), 131-139. 2

Past Medical & Social History Please answer the following questions Medical History Please check if you have ever had any of the following: Parkinson s Multiple Sclerosis Heart Disease Heart Attack High Blood Pressure Lung (COPD, Asthma) High Cholesterol/triglyceride Sexually transmitted disease Stroke/TIA Diabetes Thyroid Seizures/Epilepsy Cancer: Type Kidney/Bladder (Renal Cyst, Renal Mass, Stones) Anxiety, depression or mental illness Blood disorders (abnormal bleeding anemia, high or low white count) Other Are you pregnant? Y / N How many Pregnancies? How many children? Vaginal C-section Date of last menstrual period: Surgical History 1. Have you ever had surgery? Yes No 2. Please list approximate dates and reasons for any surgery (including childbirth): Date Surgeries Medications 1. Please list any prescription medications you are currently taking and their dosages. Medication Name Dosage Reason for taking Medications cont. 2. Please indicate if you are taking of the following over the counter medications: Aspirin Tylenol Advil/Motrin/Ibuprofen Antacid Laxatives Decongestants Antihistamines Vitamins/Mineral Supplements Other: Pharmacy Pharmacy Name: Pharmacy Address: Pharmacy Phone Number: Allergies Do you have any allergies? Yes No If yes please specify below: Social History Occupation: Marital Status: Single Married Divorced Widow Do you smoke? Yes No How much? Have you smoked in the past? Yes No How Long? Do you drink alcohol? Yes No How Much? Beer Wine Liquor Do you drink Caffeine? Yes No How Much? Coffee Tea Soda Are you on a special diet? Yes No If yes please Specify: Family History Please list all serious illnesses in your immediate family; (Example: Diabetes, Cancer, Tuberculosis, Heart disease) Mother: Age Living: Deceased- Cause: Father: Age Living: Deceased-Cause: Sister: Brother: 3

Review of symptoms Are you currently having problems with the following? Circle yes (y) or no (N) Physician Signature: Constitutional Symptoms Date: Fever Chills Integumentary Sweats Skin Rash Weakness Boils Fatigue Persistent itch Burns Eyes Skin Lesion Blurred Vision Double Vision Musculoskeletal Pain Joint pain Neck Pain Immunologic Back Pain Recurrent Fevers Recurrent Infections Ears/Nose/Throat/Mouth Malaise Ear Infection Sore Throat Neurological Sinus Problems Confusion Numbness/Tingling Genitourinary Dizzy Spells Urine Retention Headache Painful Urination Urinary Frequency Endocrine Blood in Urine Excessive Thirst Too hot/cold Respiratory Excessive Hunger Wheezing Frequent Cough Gastrointestinal Shortness of breath Abdominal Pain Nausea/Vomiting Hematologic/Lymphatic Indigestion/heartburn Swollen glands Diarrhea Blood clotting problems Bruising tendency Cardiovascular Chest Pain Psychologic Palpitations Depression Ankle Swelling Anxiety 4

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