UROGYNECOLOGY MEDICAL HISTORY QUESTIONNAIRE

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UROGYNECOLOGY MEDICAL HISTORY QUESTIONNAIRE Name: Age LMP Date: Pregnancies Births (Vaginal C/S ) Term Preterm Miscarriage/Abortion Living Weight of largest vaginal delivery Allergies: None Yes Reaction (Use the back of this page if necessary) Referring Physician: Primary Care Physician: CHIEF COMPLAINT: (The reason you want to see the doctor, what is bothering you most) Pelvic Surgery, Appearance or Function Questionnaire I have no problems with function or appearance of my vaginal/pelvic area. Skip this section. Y N I have had difficult births. Y N I have a feeling of vaginal fullness or pressure. Y N I can see or feel a bulge protruding from my vagina. Y N I push the bulge back for a BM and/or to empty my bladder. Y N I have pelvic heaviness. Y N My vagina feels loose. Y N Sex is uncomfortable at times. Y N I have pain/difficulty with sex due to my labia. Y N My labia interfere with urination. Y N My labia rub, tug or pull on my clothing. Y N I have difficulty wearing certain clothing due to my labia. Y N I have concerns about the appearance of my genital region.

BLADDER SYMPTOM QUESTIONNAIRE I have no bladder or urinary problems. Skip this section. Y N I leak urine. If Yes, how long have you been leaking urine? mo/yrs Y N I wear pads because of leaking urine. If Yes, number per day. Y N My bladder problem is bad enough that I would have surgery to fix it. Y N I have had an operation on my bladder. If Yes, how was the operation performed? vaginally abdominally Y N The operation on my bladder helped for a while. How long? Y N The operation on my bladder did not help at all. Y N I leak urine when I cough, sneeze, exercise, or move suddenly. Y N I leak urine in small spurts. Y N I leak urine in large amounts and once it starts I cannot control it. Y N If I cough hard I leak at the same time. Y N If I cough hard the leak comes a few seconds later. Y N I leak urine during sexual intercourse. Y N I feel the urge and need to urinate even if my bladder is not very full. Y N The sight, sound, or feel of running water gives me a strong urge to urinate Y N If I stand quickly from sitting or lying, I leak urine. Y N I am not aware I am losing urine until I notice I am wet. Y N I urinate more than 8 times per day. Y N The need to urinate wakes me up 2 or more times during the night. Y N I have had 2 or more bladder infections in the past year. Y N Intercourse causes me to have bladder infections. Y N It hurts to urinate. Y N I have pain in the area of my bladder. Y N My urine loss is a continual drip so that I am constantly wet. Y N After I urinate, I often feel I have not completely emptied my bladder. Y N It takes me a long time to empty my bladder. Y N My urine stream is no more than a dribble. Y N I have trouble starting the urine stream. Y N I have been treated with urethral dilation. Y N I had trouble wetting the bed as a child. Y N I have trouble wetting the bed now. BOWEL SYMPTOM QUESTIONNAIRE I have no bowel problems. Skip this section. Circle the one best answer to each of the following questions: 1. How often are you troubled with soiling yourself with solid stool? Never Fewer than 2 times/month 2 or more times/month

2. How often are troubled with soiling yourself with loose stool? Never Fewer than 2 times/month 2 or more times/month 3. How often are you constipated? Never Fewer than 2 times/month 2 or more times/month 4. How often do you have to bear down hard for a bowel movement? 5. How often do you feel you are not completely empty after a bowel movement? 6. How often do you have to use your hands or fingers to help with bowel movements? 7. How often do you find small amounts of smearing in your underwear? Y N Do you frequently pass gas when you don t want to? Y N Do you have a bowel movement at least twice a week? Y N Are you bothered by hemorrhoids? Y N Have you recently had a significant change in your bowel habits? Y N Has the size or caliber of your stool recently changed? Y N Have you recently had any black or tarry stools? Y N Have you recently had any bright red bleeding with bowel movements? Y N Are your bowel movements painful? GYNECOLOGIC QUESTIONNAIRE 1. Y N Do you have menstrual periods? If yes, date of start of last period 2. If you have periods, are they: (circle all that apply) Regular irregular heavy moderate scant painful 3. If irregular, for how long? months years 4. If painful, does pain occur before, during, or after menses? (circle) 5. If you no longer have periods: Y N Hysterectomy? Y N Removal of the ovaries? Y N Do you take or have you taken hormone replacement? 6. When was your last Pap smear? Normal Abnormal (circle) 7. Y N Have you had treatments for abnormal Paps? If yes, explain: 8. Y N Are you having any abnormal vaginal discharge or discomfort?

MEDICAL HISTORY None High blood pressure Blood clots Diabetes Heart disease Digestive Asthma Blood transfusions TB Cancer Kidney disease Glaucoma HIV Varicose veins Stroke Depression/Anxiety Trauma/Violence Other Psychiatric problems Anesthesia complications Liver problems Breast problems Thyroid problems Sexually transmitted disease Breast problems Abnormal Pap SURGICAL HISTORY None C-section. How many? Appendectomy Hysterectomy. Abdominal Vaginal Ovaries removed. Both Right Left Incontinence surgery. Type: Prolapse surgery. Type: Abdominal surgery. Type: Hernia surgery. Type: Tubal ligation D&C Back surgery Hip surgery Foot surg Diagnostic laparoscopy Tonsils Gallbladder FAMILY HISTORY (Significant problems) Paternal Grandfather None Paternal Grandmother None Maternal Grandfather None Maternal Grandmother None Father None Mother None Brother None Sister None Other None SOCIAL HISTORY Marital status: S M W D (circle) Occupation: Not working Working. What occupation Tobacco: Never or Daily amount Number of years Alcohol Never or Daily amount Type Drug use. Never or Type Abuse Never or Describe Exercise Daily Couple of times/week Weekly

Y N Are you sexually active? Are your partner(s) (circle) Men Women Both Y N Are you or your partner using birth control now? If so, what method? (circle) Condom Pill IUD Surgical Spermicide Implant Rhythm Injection Inserts None N/A Y N Are you satisfied with this method? Y N Do you need birth control? MEDICATIONS (use the back of this page if necessary) Medication Dosage Frequency Taken 1. 2. 3. 4. 5. ALLERGIES None Penicillin Sulfa IV Dye Iodine/Betadine Other w/reaction

ROS CIRCLE ANY SYMPTOMS YOU CURRENTLY HAVE General None Fever Chills Weight Loss Fatigue Weakness Loss of appetite Skin None Rash Itching Hair loss Non-healing sores Ears, Nose, None Headache Hearing loss Ringing in ears Throat Earache Ear discharge Nosebleeds Congestion Sore throat Bleeding gums Hearing aid Eyes None Blurring Double vision Sensitivity to light Eye pain Eye discharge Eye redness Excess tearing Vision loss Cataracts Glaucoma Glasses Contacts Heart None Chest pain Palpitations Breathing discomfort when lying Muscle pain when walking Leg swelling Murmur Fainting Varicose veins/phlebitis Lungs None Cough Coughing blood Sputum production Shortness of breath Wheezing Bronchitis Asthma GI None Heartburn Nausea Vomiting Abdominal pain Diarrhea Constipation Bloody stools Dark tarry stools Involuntary loss of gas or stool GU None Burning with urination Urinary urgency Frequency Bloody urine Flank pain Abnormal vaginal discharge Abnormal vaginal bleeding Vaginal dryness Involuntary urine loss Muscles None Muscle aches Neck pain Back pain Joint pain Falls Skeleton Stiffness Weakness Cramps Endocrine None Easy bruising/bleeding Environmental allergies Excessive thirst/sweating Hot flashes Weight gain/loss Loss of height Heme/Lymph None Anemia Transfusions Immune None Hay fever Persistent infections Seasonal allergies HIV exposure Neurological None Dizziness Tingling Tremor Sensory changes Speech changes Weakness Seizures Vertigo Convulsions Blackouts Vertigo Phych None Depression Thoughts of suicide Substance abuse Hallucinations Nervous/Anxiety Insomnia Mood swings Memory loss

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