Loyola University Medical Center Female Pelvic Medicine & Reconstructive Surgery

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Loyola University Medical Center Female Pelvic Medicine & Reconstructive Surgery Medical History Questionnaire Name: Date: Age: D.O.B. Race: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary). Physician to send letter (primary care or referring physician) to: Print Physician Name Are you seeing any other health care providers today 1. If yes, who else do you have an appointment with? (Physical Therapy/Psychology/Dr. Summers/Dr. Liszek/Dr. Bressler ) What is your current pain score? 6 7 8 9 10 No pain minimal mild moderate severe the worst pain you have ever felt When did the pain start? 2. Was there an event that started the pain How long have you had this pain? Please check the term that best describes your pain: throbbing stabbing sharp shooting cramping hot/burning aching heavy Please indicate from the following list anything that makes the pain worse periods ovulation intercourse exercise 3. physical activity Standing/lifting urinating bowel movements constipation diarrhea Other

A. What types of treatments have been tried for your pain so far? B. What health care providers have you seen for the pain so far? C. Surgeries for pain? Please list 4. D. What tests have been done to evaluate the cause of your pain? E. Do you have these results today? F. If not, please provide the information for obtaining the records We will ask you to sign a release of health information consent so that we can obtain these records in order to treat your condition Ultrasound: date(s) MRI CT scan: date(s) Other X-rays Biopsies GYNECOLOGICAL HISTORY Do you have a diagnosis of a gynecological disorder? If yes, what is the disorder called? (check box that applies). Endometriosis Polycystic ovarian cystic disease Ovarian Cysts Uterine Fibroids Adenomyosis vuvlodynia Infections Adhesions Other Last Menstrual period? 5. How old were you when your periods started? Describe the quantity of flow? (check box that applies) Light Medium Heavy Clots Varies Do you have pain associated with your periods? Before After During If yes, how do you rate the pain before your periods? Number from 1-10 How many days does the period last? How often do you get your p eriod?

6. BLADDER Do you have a diagnosis of a bladder disorder? Do you experience any of the following? Urinary Tract Infections? Painful Bladder/Interstitial Cystitis Overactive Bladder Urge to urinate Feeling of fullness after urination Frequent Urination at night 7. BOWEL Do you have a diagnosis of a bowel disorder? Irritable Bowel Crohns Colitis Constipation Adhesions Celiac Disease Inflammatory Bowel Disorder Anorexia Is there discomfort or pain associated with your bowel movements? Bulimia Other Do you have to strain to move your bowels? if yes, how often? Do you feel an urgency to move your bowels? if yes, how often? Feeling of incomplete emptying after a bowel movement? Nausea? If so, what causes it? Vomiting? If so, when? 8. Do you have uncontrollable vomiting? Blood in your stool? Is there anyone in your family with colon or other gastrointestinal cancer? Anyone in the family with other gastrointestinal diseases such as inflammatory bowel disease? Have you lost weight because of your abdominal/pelvic pain?

9. Pelvic Floor Do you experience pressure in the pelvis or lower abdomen? Do you feel a bulge or something falling out of the vagina? Do you feel a burning or stinging sensation in the pelvic region? Do you have redness or a rash on the vulva? Do these symptoms affect your ability to have intercourse? Do these symptoms affect your ability to wear tampons? Do these symptoms affect your ability to do physical activity Yes Quality of Life Questions: 10. In general, how much does your pain problem interfere with your day-to-day activities? No interference Extreme interference 11 Since the time you developed a pain problem, how much has you pain changed your ability to work No interference Extreme interference 12. Check here, if you have retired for reasons other than your pain problem How much has your pain changed the amount of satisfaction or enjoyment you get from participating in social and recreational activities? No change Extreme change 13 How supportive or helpful is your spouse (significant other) to you in relation to your pain? Not at all supportive Extremely supportive 14 Rate your overall mood during the past week. Extremely low mood Extremely high mood A. Are you currently sexually active? B. If so, does your pain affect your intimacy? C. What things have you tried to help with painful intercourse? D. E. Have you experienced sexual abuse every in your life? If you answer yes, please discuss with your provider today Do you feel that you are in a harmful environment in your home? F.. Does anyone threaten or abuse you in your home or workplace G. Do you have trouble sleeping? If so, why? H. Do you have a diagnosis of depression? Anxiety? Bipolar disorder? H. Other psychiatric Diagnosis? I. Are you currently under treatment for this condition? J. Are you currently in the care of a mental health care professional?

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