Northeast Ohio Urogynecology Patient History Intake Form. Last Name First Name Age. Date of Birth Race Referring Physician.

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Northeast Ohio Urogynecology Patient History Intake Form Last Name _First Name Age_ Date of Birth Race Referring Physician Reason for Visit: _ Allergies: Preferred Lab (circle): QUEST LABCARE PLUS LABCORP OTHER Pharmacy Name/phone Number: Medical History: Which of the following conditions are you currently being treated or have been treated for in the past (please check)? Heart disease / Murmur / Angina Shortness of breathe Eye disorder / Glaucoma Diabetes High cholesterol Asthma Kidney / Bladder problems Seizures High blood pressure Lung problems / cough Stroke Liver problems / Hepatitis Blood Clot Sinus problems Headaches /Migraines Arthritis Heartburn (reflux) Seasonal allergies Neurological problems Cancer Anemia or blood problems Tonsillitis Depression / Anxiety Ulcers/colitis Swollen ankles Psychiatric care Thyroid problems Past Surgical History: Hysterectomy Date:_ Incision: Abdominal Vaginal Bladder Sling Date:_ Type: Mesh Fascial/Cadaveric Prolapse Surgery Date:_ Type: Mesh Non-mesh Major Abdominal Laparoscopic Abdominal OB/GYN History: # of pregnancies: # of vaginal births: # of C-sections: Premenopausal Peri-menopausal Menopausal Do you use hormone replacement? Oral contraception Oral HRT Vaginal estrogen Social History: Alcohol Drugs Cigarettes Single Married Divorced Family History: Cancer Bleeding Disorders Heart Disease Diabetes Hypertension

Northeast Ohio Urogynecology Patient Medication List Please write down all of your medications below or provide an attached list. Name Prescription Medications Over-the-Counter Medications Name Dose Name Dose

Northeast Ohio Urogynecology Reveiew of Systems Name General/Constitutional Appetite Fatigue Fever Weight change HEENT/Neck Change in vision Hearing loss Nasal congestion Hoarseness Sore throat Endocrine Cold intolerance Excessive thirst Excessive urination Heat intolerance Respiratory Chronic Cough Shortness of breath Wheezing Cardiovascular Chest pain Leg Swelling Palpitations Varicose veins Gastrointestinal Abdominal Pain Bloating Blood in Stool Change in Bowel Habits Heartburn Incontinence of Stool Nausea Vomiting Hematology Anemia Easy bleeding Easy bruising Women Only Vaginal Dryness Low libido Pain with sex Heavy periods Hot Flashes Irregular periods Genitourinary Blood in urine Burning on urination Urinary tract infections Urinary Incontinence Vaginal discharge Vaginal Pressure/Bulge Musculoskeletal Back pain Joint pain Joint stiffness Muscle pain Tingling/numbness Neurologic Confusion Dizziness Headache Seizure Mental Health Anxiety Depression Sleep Disturbances

Name Pelvic Floor Symptom Survey Instructions: Please answer all of the questions in the following survey. Answer these by circling the appropriate number. While answering these questions, please consider your symptoms over the last 3 months. Symptoms Present = YES: Not Present = NO: 1 = not at all, 2 = somewhat, 3 = moderately, 4 = quite a bit 0 = not presents Pelvic Organ Prolapse Symptoms 1. Usually experience pressure in the lower abdomen? 2. Usually experience heaviness or dullness in the pelvic area? 3. Usually have a bulge or something falling out that you can see or feel in your vaginal area? 4. Ever have to push on the vagina or around the rectum to have or complete a bowel movement? 5. Usually experience a feeling of incomplete bladder emptying? 6. Ever have to push up on a bulge in the vaginal area with your fingers to start or complete urination? Bowel Symptoms 7. Feel you need to strain too hard to have a bowel movement? 8. Feel you have not completely emptied your bowels at the end of a bowel movement? 9. Usually lose stool beyond your control if your stool is well formed? 10. Usually lose stool beyond your control if your stool is loose? 11. Usually lose gas from the rectum beyond your control? 12. Usually have pain when you pass your stool? 13. Experience a strong sense of urgency and have to rush to the bathroom to have a bowel movement? 14. Does part of your bowel ever pass through the rectum and bulge outside during or after a bowel movement? Urinary Symptoms 15. Usually experience frequent urination? 16. Usually experience urine leakage associated with it feeling of urgency, that is, a strong sensation of needing to go to the bathroom? 17. Usually experience urine leakage related to coughing, sneezing, or laughing? 18. Usually experience small amounts of urine leakage (that is, drops)? 19. Usually experience difficulty emptying your bladder? 20. Usually experience pain or discomfort in the lower abdomen or genital region?

Northeast Ohio Urogynecology Sexual Function Questionnaire Are you currently sexually active? o No. Please circle reason: I am not able I have too much pain I have no desire I do not have a partner My partner is not able o Yes. Proceed with next 12 questions 1. Do you feel pain during sexual intercourse? 2. Are you incontinent of urine (leak urine) with sexual activity? 3. Does fear of incontinence (either stool or urine) restrict you sexual activity? 4. Do you avoid sexual intercourse because of bulging of the vagina (either bladder, rectum, or vagina falling out?)

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