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Transcription:

Urogynecology New Patient Information Form NAME: UROGYNECOLOGY: NEW PATIENT INFORMATION FORM Why are you coming for this evaluation? How long have you had this problem? Has it been getting worse? yes no What treatments have you tried? _ MEDICATIONS & SUPPLEMENTS: Please list all medications you are currently taking (including any over- the- counter medications, vitamins, or herbal supplements/home remedies). Include dosage and how often you take it. If you need more room, please list all medications on a separate sheet of paper and attach it to this packet. Medication Name Dosage How Often Preferred Pharmacy: Phone: Address/Location: _ ALLERGIES/MEDICATION REACTIONS: Are you allergic to latex? no yes: if yes, please list reaction: Please list all medication allergies or reactions below, including the type of reaction experienced. If you need more room please list all medications & reactions on a separate sheet and attach it to this packet. Medication Name Type of Reaction (hives/rash, itching, shortness of breath, nausea, etc.)

Urogynecology Page 2 MEDICAL HISTORY: Number of: Pregnancies Vaginal Deliveries C- Sections HEME RESP Medical Problems Asthma Chronic cough Chronic Obstructive Pulmonary Disease (COPD) Blood clot in leg or arm Blood clot in lung Blood disorder- circle specific problem chronic anemia, von Willebrand's disease, sickle cell trait/disease, thalasemia, hemophilia Please check one: Current problem Past Problem Never a problem Heart Disease- circle specific problem heart attack, coronary artery disease, angina, congestive heart failure, stent placement ENDO CARDIAC Heart Condition- circle specific problem abnormal beats or rhythm, murmur, pacemaker, artificial valves High Blood Pressure Stroke Transient Ischemic Attack (TIA) Diabetes - circle specific treatment diet- controlled, oral medications, insulin shots Thyroid Disease- circle one: hypo- or hyper- NEURO MSK GI GU Kidney Disease- circle specific problem polycystic kidneys, renal insufficiency, renal failure (on dialysis), anatomic abnormalityof kidneys or ureters Kidney Stones Recurrent Bladder Infections (UTI)- > 3/year Interstitial Cystitis Abnormal Pap Smear- year: Irritable Bowel Syndrome- circle type diarrhea- predominant, constipation- predominant, mixed Chronic constipation Acid Reflux/chronic heartburn Liver disease- type: Arthritis- circle type osteo-, rheumatoid, psoriatic Fibromyalgia Epilepsy/Seizure Disorder Parkinson's Disease Multiple Sclerosis

Urogynecology Page 3 PSYCH OTHER Medical problems, continued Current Past Never Depression Anxiety Cognitive Impairment or Dementia Glaucoma- circle type: wide/open or narrow/closed Chronic Pain- Location: Cancer- circle type breast, cervical, endometrial/uterine, ovarian, bladder, kidney, other: Other: Other: SURGICAL HISTORY: Please list all past surgeries. I f you need more room, please list all surgeries on a separate sheet and attach to this packet. Hysterectomy? no yes: year Route- abdominal incision laparoscopic vaginal Removal of ovaries? no yes: both right left Year Type of Surgery Surgeon/Hospital Complications SOCIAL HISTORY: Do you No Past Use Yes Use tobacco? Use recreational drugs? Drink alcohol? # packs per day: # years of use: Type: How often? Type: # drinks per week:

Urogynecology Page 4 Occupation: retired disabled Are you currently sexually active? no yes Have you been sexually abused? no yes: as a child as an adult currently Have you been physically abused? no yes: as a child as an adult currently Are you a primary caregiver to someone? no yes: relationship: Marital/Relationship status married single divorced separated other: Who do you live with? alone spouse/significant other family other: What is your usual level of physical activity? very active & exercise regularly active a little active not active What is your current mobility level? walk without any problems or assistive devices need a cane or walker need help getting on an exam table use a wheelchair FAMILY HISTORY: check here if you are adopted and do not have this information Has anyone in your family (blood relative) been diagnosed with any of the following? Medical Problem Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Father Mother Brother Sister Other Bleeding or clotting problem (von Willebrands, hemophilia, platelet disorder, Factor V Leiden) Breast Cancer Colon or Rectal Cancer Diabetes Endometrial or Uterine Cancer Heart Attack Heart Disease Ovarian Cancer Stroke or TIA Other: Other:

Urogynecology Page 5 REVIEW OF SYSTEMS: Circle any of the following symptoms you are currently experiencing: Constitutional Skin HENT Eyes Cardiovascular Respiratory GI MSK Endo/Heme/Imm Neuro Psych fever chills weight loss weight gain malaise/fatigue sweating night sweats weakness rash itching headaches hearing loss ringing in ears ear pain ear discharge nosebleeds congestion sore throat blurry vision double vision pain with light in eyes eye pain eye discharge eye redness chest pain palpitations shortness of breath with lying down leg pain with walking leg swelling waking up at night short of breath cough coughing up blood productive cough shortness of breath wheezing heartburn nausea/vomiting abdominal pain diarrhea constipation blood in stool dark, tarry stools bloating muscle pain/aches neck pain back pain joint pain frequent falls easy bruising/bleeding allergies feeling too thirsty dizziness tingling/numbness tremor change in sensation change in speech weakness in one arm or leg seizures passing out/fainting depression suicidal ideas substance abuse hallucinations anxiety insomnia memory loss UROGYNECOLOGY: Were you treated for 3 or more bladder infections in the last year? no yes Do you have difficulty emptying your bladder? no yes Do you have pain when you urinate? no yes How many times do you get up to empty your bladder at night? 0 /rarely 1-2 3-4 5 or more How often do you have bowel movements? daily every other day 1-2 times a week less than once per week Do you leak stool? no yes: liquid stool loose stool soft stool formed stool If you experience URINARY INCONTINENCE: Do you Usually have an urge to urinate before you leak urine? no yes Leak urine or rush to the bathroom when you see/feel/hear running water? no yes Leak urine or rush to the bathroom when you approach your home after being out? no yes Leak urine when you cough, sneeze, laugh, or exercise? no yes Wet the bed when you are completely asleep? no yes Feel like you leak urine constantly? no yes Wear pads to protect your clothing from leakage of urine? no yes If you do wear pads: What kind? pantiliner thin pad thick pad diaper

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