Name: Date: Referring Provider: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary).

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Transcription:

Name: Date: Referring Provider: Age: D.O.B. Race/ ethnicity: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary). We are interested in learning more about how your bowels and bladder work in your typical or usual week while you are doing regular activities - Please place an X under the appropriate answer. 1. In a typical week, do you have frequent, strong urges to urinate? 2. In a typical week, do you leak urine when you do not want to? 3. In a typical week, do you have difficulty emptying your bladder? 4. In a typical week without the use of laxatives (enema, suppository, oral laxative), how many bowel movements do you have? # 5. In a typical week, how many laxatives do you use? 6. In a typical week, do you have difficulty having bowel movements? (pain, hard bowel movements, strain or use your hand to get the stool out) 7. In a typical week, do you lose stool or bowel movement when you do not want to? 8. Do you feel like your rectum, bladder, uterus, or vagina is falling out? 9. Do you have any physical problems with sexual relations? # Does not apply 10. During the night, how many times did you have to get up to urinate on average? ne One Two Three Four or more

Past Medical History: Check ( ) if your answer is yes. As an adult, have you had: Heart disease Liver disease Asthma Heart murmur Tuberculosis Jaundice Obstetrical History: Kidney disease Thyroid disease Diabetes Kidney infection Pneumonia Cancer Bladder infection Bowel disease High blood pressure Parkinsonism Stroke Nerve disorder Serious injuries Arthritis/Other joint problems Number of pregnancies Number of children born Total number of cesarean sections Weight of largest infant born During delivery, did you ever have a tear in the rectum? During delivery, were forceps used? Did you ever have a vacuum assisted delivery? Gynecological History: Date of last menstrual period Method of birth control Are you sexually active at this time? If yes, how long have you been with your current partner? Is your sex life satisfactory for you? Surgical History: If you have had any operations, please list them here: Surgery Date Surgeon

Cancer Screening History: Date of last pap smear: Date of last mammogram: Date of last screen for colorectal cancer: Was it normal? Was it normal? Colonoscopy Sigmoidoscopy Stool test for blood Family History: Has anyone in your family had any of these diseases? If so, please give relationship to you. Breast Cancer Heart Disease Ovarian Cancer Other Cancer(s), please list: Other Disease(s), please list: Social/Family Supports: Who is your main support person (partner/spouse/friend)? Health Habits: Do you smoke? Quit - when? Do you drink alcohol? Do you exercise regularly? How often do you exercise? What type of exercise do you do? Medicines/Physicians: List any drug allergies: Please list your doctors, all medications they prescribe for you and the dosage (if possible). Doctor: Medications: Doctor: Medications: Doctor Medications Please list any other herbs/supplements you take:

General Symptoms: Please check ( ) if you recently had: Constitutional: Fever, chills Change in appetite Excessive water drinking Sweating at night Loss of hair Weakness Recent weight loss Intolerance to heat Fatigue Recent weight gain Intolerance to cold Ears, se, Mouth and Throat Respiratory Eyes: Ear pain of ear infections Sores in mouth/bleeding gums Ringing in ears Hoarseness Glaucoma Decreased hearing Sinus infections Throat infections Blurry vision Cardiovascular: Cough Difficulty breathing Swelling of legs Coughing with blood With laying down Varicose veins Chest x-ray, if so, Date: With exercise Heart murmur Gastrointestinal: During sleep Bad food digestion Difficulty swallowing Hemorrhoids Change in bowel habits Nausea Vomiting Neurological: Vomiting blood Diarrhea Black stool Musculoskeletal: Pain in legs with exercise Skin: Fainting Convulsions Itching Tremors Severe headaches Stroke Dizziness Skin rashes Skin infections Change in any mole Psychiatric: Endocrine: Psychiatric treatment Breast lump Depression Breast size change Thoughts of suicide Nipple discharge Nervousness Hematologic/Lymphatic: Breast pain Blood clots Easy bruising Prolonged bleeding Low blood count (anemia) Allergic/Immunologic: Hayfever Other: Asthma Enlarged thyroid Gland enlargement in Frequent bloody nose

Pelvic Floor Questionnaire (PFDI) Instructions: Please answer the following questions by placing an X in the appropriate box. If you are unsure about how to answer a question, give the best answer you can. While answering these questions, please consider your symptoms over the last three months. Thank you for your help. Date: / / 1. Do you usually experience pressure in the lower abdomen? t at all Somewhat Moderately Quite a bit 2. Do you usually experience heaviness or dullness in the pelvic area? t at all Somewhat Moderately Quite a bit 3. Do you usually have a bulge or something falling out that you can see or feel in the vaginal area? t at all Somewhat Moderately Quite a bit 4. Do you usually have to push on the vagina or around the rectum to have or complete bowel movement? t at all Somewhat Moderately Quite a bit 5. Do you usually experience a feeling or incomplete bladder emptying? t at all Somewhat Moderately Quite a bit 6. Do you ever have to push up on a bulge in the vaginal area with your fingers to start or complete urination? t at all Somewhat Moderately Quite a bit 7. Do you feel you need to strain too hard to have a bowel movement? If other than never, how much does this t at all Somewhat Moderately Quite a bit 8. Do you feel you have not completely emptied your bowels at the end of a bowel movement? If other than never, how much does this t at all Somewhat Moderately Quite a bit 9. Do you usually lose stool beyond your control if your stool is well formed? t at all Somewhat Moderately Quite a bit 10. Do you usually lose stool beyond your control if your stool is loose or liquid? t at all Somewhat Moderately Quite a bit

11. Do you usually lose gas from the rectum beyond your control? 12. Do you usually have pain when you pass your stool? 13. Do you experience a strong sense of urgency and have to rush to the bathroom to have a bowel movement? If other than never, how much does this t at all Somewhat Moderately Quite a bit t at all Somewhat Moderately Quite a bit t at all Somewhat Moderately Quite a bit 14. Does a part of your bowel ever pass through the rectum and bulge outside during or after a bowel movement? 15. Do you usually experience frequent urination? t at all Somewhat Moderately Quite a bit t at all Somewhat Moderately Quite a bit 16. Do you usually experience urine leakage associated with a feeling of urgency that is a strong sensation of needing to go to the bathroom? 17. Do you usually experience urine leakage related to coughing, sneezing, or laughing? 18. Do you usually experience small amounts of urine leakage (that is, drops)? 19. Do you usually experience difficulty emptying your bladder? 20. Do you usually experience pain or discomfort in the lower abdomen or genital region? t at all Somewhat Moderately Quite a bit t at all Somewhat Moderately Quite a bit t at all Somewhat Moderately Quite a bit t at all Somewhat Moderately Quite a bit t at all Somewhat Moderately Quite a bit

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