88-327(R.8108)

Name Age Date _____ _

Referred by----------------------~~~~~ Reason for visit Do you have annual checkups with a family doctor or internist? DY es 0 No Physician Date of last visit

MEDICAL ILLNESS/PROBLEMS (Please list)

Have you had problems with any of the following conditions? o High blood pressure o Diabetes o Chicken pox o Bladder infections o Hepatitis o Depression o Thyroid disease o Asthma o Anxiety o Kidney disease o Anemia o Sleep problems o Breast disease o Sinus problems o Heart disease o Bowel problems o Blood clots o Lung disease o Eating disorder o Fibroids o Rheumatic fever

OPERATIONS Procedure

OBSTETRIC IDSTORY

Date Hospital

How many times have you been pregnant? -----

o Seizures o Blood transfusion o Reflux o Migraines o Bladder problems o Autoimmune disease

Complications

Number of vaginal deliveries? Number of Cesarean sections? ____ _ Reason for Cesarean section? -----------------------· Number of living children? Number of adopted children? ____ _ Number of miscarriages? Number of elective abortions? ____ _ Number of pregnancies in your tubes? Number of stillbirths? ____ _ Number of premature births? Largest baby? ____ _ Any complications of pregnancy? --------------------­Any problems with postpartum depression? ----------------­Do you wish to have more children? Vaccinations: Hepatitis A __ Hepatitis B _ Intluenza __ Measles/Mumps/Rubella _ _ Meningococcal __ Polio __ Diphtheriarretanus __ Pneumococcal __ HPV __ Varicella __ (Had the chicken pox___)

... ·.)r~ on .1 ·ns

Patient Name:

PAGE 1 of4

88-327 (R.8106)

GYNECOLOGICAL HISTORY . Date of the first day of your last menstrual period? Normal? 0 Yes 0 No ----What do you use for birth control? Satisfied? 0 Yes D No Menstrual cycles come every days and last for days. Age of your first menstrual period? __ _ Any recent changes in your period? 0 Yes 0 No(Ifyes,pleaseexplain)

Do you have any of the following: Excessivepainwithyourperiods? Excessive bleeding with your periods? Premenstrual symptoms (PMS)?

DYes OYes OYes

ONo ONo ONo

Explain ----------------~~-------~~--

Date of your last period 0 Normal 0 Abnormal Have you ever had an abnormal pap smear? 0 Yes 0 No Date -------Date oflast mammogram 0 Normal 0 Abnormal Doyoudoselfbreastexams? DYes ONo

Areyoucurrentlysexuallyactive? DYes ONo Need birthcontrol?OYes DNo Are your partners: 0 Men 0 Women 0 Both Do you have pain with sexual relations? 0 Yes 0 No Do you have any questions regarding sexual relations? DY es 0 No

Have you ever had a sexually transmitted disease? 0 Yes 0 No P Herpes 0 Venereal Warts O Chlamydia 0 OHTV 0 DL 0 Gonorrhea D Syphilis 0 Pelvic Inflammatory Disease DOther (list) -------------------------

Haveyoustoppedhavingmenstrualperiods? ONo DYes When? Hysterectomy? 0 Yes 0 No Surgical removal of your ovaries? 0 Yes 0 No Do you take hormonal replacement therapy? 0 Yes 0 No If yes, which medications and how do you take them? -------------

Haveyouhadanyvaginal bleeding since menopause? 0 Yes 0 No Do you have: Accidental loss of urine 0 Yes 0 No Vaginal dryness 0 Yes 0 No

Accidental loss of feces 0 Yes 0 No Accidental loss of gas 0 Yes 0 No Pain with sexual relations 0 Yes 0 No Pelvic pressure 0 Yes 0 No

MEDICATIONS (Please list all medications/herbs/treatments that you are taking) I. 4. 7. ----------2. 5. 8. ----------3. 6. 9.

ALLERGIES:

'

Patient Name:

PAGE 2 of 4

FAMILY HISTORY: (Haveyouhadanybloodrelativesw1 anyof e o owing: D High blood pressure D Highcholesterol

D Diabetes D Colon cancer D Breast cancer D Heart disease D Cervical cancer D Ovarian cancer

D Uterine cancer D Mental illness D Osteoporosis D Blood clots D Stroke D Lung disease D Urinary infections D Kidney disease

D Bowel disease D Respiratory disease D Skin disease D Blood clots D Hepatitis D Epilepsy [l Arthriti~ [l Rlnnrl rl i~nrrli::.r~ D Cancer (type)

Areyouadopted? DYes D NJ

SOCIAL WSTORY: Are you: D Single 0 Married 0 Partnered 0 Divorced D Separated D Widowed Do you smoke?: o No D Yes Howmuch? How long? ==== Do you drink alcohol? o No o Rarely o OccaslOnally o Often o Daily Do you use drugs socially? o No o Rarely o Occasionally o Often o Daily

D Pot D Cocaine D Crack D Methamphetamine o Other

Do you exe-rc..,..is-e~r-e..-gu_,l .... a"""rly-.?~D~N-o- D Yes How many times a waek? - -===,.....,,,.,,.,-=--==

Last grade of school attende_~d=----..,,.---~-==-====---========== Occupation;.,.......~---_,.,,.....,,...,.~-~~--...,._,==........,========

Have you been physically or mentally abused by your spouse or partner? D Yes D No Have you ever been sexually abused or raped? o Yes o No Explain

--------~~-~---------------

REVIEW OF SYSTEMS: Do you CURRENTLY have any of the following problems? Pleasecircleallthatapplytoyou right now. If none apply, write none. CONSTITUTIONAL: Weightloss Weightgain Fever Fatigue Other Explain _____ _____________________ _

EYES: Double vision Spots before eyes Vision changes Other Explain - - -------------------------ENT/MOUTH: Earaches Ringing in ears Sinus problems Headaches Mouth sores

Sore throat Dental problems Other

CARDIOVASCULAR: Chest pain Chest palpitations Painful breathing Swelling Other

Explain ___ ........ ==---=:=~--------------------

RESPIRATORY: Wheezing Shortness of breath Chronic cough Other Explain

ft '" ~lr- • [) · ·~~~ ke.r~ r I 11:1 ":J j& 11'!f\" II fem 1t t't>

Patient Name:

________ ......_ ____ _.;;.... __ __, M.R.# ------~--:~---~·----

88-327 (R 8106) PAGE 3 of 4

REVIEW OF SYSTEMS: (continued) GASTROINTESTINAL: Diarrhea Constipation Bloody stools Nausea/vomiting Other Explain _________________________ ____ _

URINARY: Blood in urine Pain with urination Urinary frequency Urgency Incomplete emptying Leak of urine with cough Other

GENITAL: Painful periods Painful intercourse Irregular periods Vaginal discharge Heavy periods Other

Explain _____________________________ _

MUSCULOSKELETAL: Weakness Muscle pain Other Explrun _____________________________ _

SKIN/BREAST: Pain in breast Lump in breast Nipple discharge Rash Other

Explain _____________________________ _

NEUROLOGICAL: Dizziness Seizures Numbness Difficulty walking Other Explrun _____________________________ _

PSYCHIATRIC: Depressed mood Frequent crying Seeing things Hearing voices Other

Explain _____________________________ _

ENDOCRINE: Hot flashes Abnormal thirst Increased body/facial hair Other Explain

-----------------------------~

HEMA TO LOGIC: Frequent bruising Cuts that do not stop bleeding Enlarged lymph nodes

Explain __________ ___________________ _

ALLERGY/IMMUNO: Allergies Hay fever Other Explain _____ ________________________ _

ANY OTHER CONCERNS OR QUESTIONS?

Thank you for taking the time to fill out this questionnaire.

Patient Date ----------------- ---(signature) D 1 reviewed this with my patient

--------------------~ (MD signature)

,.

Patient Name:

~-------------------1 M.R . #-----------------~

88-327 (R. 8106) PAGE 4 of 4

Name: Date:

Medical#:

Circle the one number that best describes how your urinary tract condition is now. Normal Mild Moderate Severe

1 2 3 4

Describe your problem(s): For example: "I have trouble getting to the bathroom on time." Or "I feel something is fall ing, or bulging out of my vagina."

If you have more than one problem, which one bothers you the most?

How Jong have you had this problem?

How often does this problem bother you? Daily Weekly Monthly Rarely Never

How much does this problem bother you? Mildly Moderately Severely

Would you choose surgery if this could help your problem? Yes No Don' t Know

On a typical day, how many times do you empty your bladder?

On a typical night, how many times do you empty your bladder?

How many bladder infections (urinary tract infections) have you had in the past year?

Do you wear pads (or anything else) for urine leakage? Yes No

If yes: I wear: Tissue Mini Pads Regular Pads Heavy pads (or diaper)

I change my pads times per day; I change my pads times per night.

When I change my pads they are: Damp (only a few drops) Wet Soaked

Have you tried: (plca.:ic nn:iwcr nil)

Kegels (vaginal exercises)? Yes No If yes: Did it help? Yes No

Medicine for bladder control? Yes No If yes: Did it help? Yes No

Pessary ( a vaginal insert)? Yes No If yes: Did it help? Yes No

Page 1of3

Pelvic Floor Distress Inventory - Short Form 20

Instructions: Please answer these questions by putting 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 3 months. Thank you for your help.

Name: Date:

DOB:

If yes, how much does this bother you?

NO YES Not at All Somewhat Moderately Quite a bit

0 1 2 3 4

1. Do you usually experience pressure in the lower abdomen?

2. Do you usually experience heaviness or dullness in the pelvic area?

3. Do you usually have a bulge or something falling out that you can see or feel in the vaginal area?

4. Do you usually have to push on the vagina or around the rectum to have or complete a bowel movement?

5. Do you usually experience a feeling of incomplete bladder emptying?

6. Do you ever have to push up on a bulge in the vaginal area with your fingers to start or complete urination?

7. Do you feel you need to strain too hard to have a bowel movement?

8. Do you feel you have not completely emptied your bowels at the end of a bowel movement?

9. Do you usually lose stool beyond your control if your stool is well fonned?

10. Do you usually Jose stool beyond your control if vour stool is loose or liquid?

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 huvc to ru;jh to th1:> buthroo1n to huve .. b ow<:!

movement? 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?

Page 2of3

If yes, how much does this bother you?

NO YES Not at All Somewhat Moderately Quite a bit

0 1 2 3 4

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?

21. Do you often have pain or burning when you empty your bladder?

22. Do you have pain when your bladder is full?

23. Do you wet the bed at night while you are sleeping?

24. Is your sex life affected by any of your symptoms?

I STRESS SYMPTOMS Never Rarelv Sometimes Often l

Does coughing gently cause you to lose urine? (Would you say .. ) 0 I 2 3

'Does coughing hard cause you to lose urine? (Would you saY ... ) 0 l 2 3 I Does sneezing cause you to lose urine? 0 I 2 3

Does lifting things cause you to lose urine? 0 1 2 3 I Does bending cause you to lose urine? 0 I 2 3

looes lauclling cause you to lose urine? 0 I 2 3 I Does walking briskly or io1?1?ing cause you to lose urine? 0 1 2 3

Does straining, if you are constipated, cause you to lose urine? 0 1 2 3 I Does getting up from a sitting to a standing position cause you to lose urine? 0 1 2 3

I URGE SYMPTOMS Never Rarely Sometimes Often l Some women receive very little warning and suddenly find that they are losing, or are about to lose urine beyond their control. How often does this happen to you? 0 I 2 3 r you can't find a toilet or find that the toilet is occupied, and you have an urge to urinate. how often do you end up losing urine or wetting yourself'? Would you saY .... ) 0 1 2 3

Do you lose urine when you suddenly have the feeling that your bladder is verv full? 0 1 2 3

lnoes washing your hands cause you to lose urine? 0 1 2 3

Does cold weather cause you to lose urine? 0 I 2 3

looes drinking cold beverages cause you to lose urine? 0 1 2 3

Page 3of3

INSTRUCTIONS Some women find that bladder, bowel or vaginal symptoms affect their activities, relationships, and feelings. For each question, place an X in the response that best describes how much your activities, relationships or feelings have been affected by your bladder, bowel or vagi nal symptoms or conditions over the last 3 months. You may or may not have symptoms in each of these three areas, but please be sure to mark an answer in all 3 columns for each question. If do not have symptoms in one of these areas, then the appropriate answer would be "Not at all" in the corresponding column for each question.

EXAMPLE For the following question:

If your bladder symptoms interfere with your ability to drive a car moderately, and your bowel symptoms interfere with your abi lity to drive a car somewhat, but your vaginal or pelvic symptoms do not interfere with your ability to drive a car or you have no vaginal or pelvic symptoms then you should place an X in the corresponding boxes as indicated below:

How do symptoms or conditions related to the following • • • • Bladder or Bowel or Vagi11a or usually affect your J. uri11e rectum Pelvis

1. ability to drive a car D Not at all D Not at all M Notatall D Somewhat )ll Somewhat D Somewhat

)Q Moderately D Moderately D Moderately D Quite a bit D Quite a bit D Quite a bit

Please make sure to answer all 3 columns for each and every question. Thank you for your cooperation

Pelvic Floor Impact Questionnaire - short form 7

Instructions: Some women find that bladder, bowel or vaginal symptoms affect their activities, relationships, and feelings. For each question, place an X in the response that best describes how much your activities, relationships or feelings have been affected by your bladder, bowel or vaginal symptoms or conditions over the las t 3 months. Please be sure to mark an answer in all 3 columns for each question. Thank you for your cooperation.

How do symptoms or conditions related to the following -+-+-+-+ Bladder or Bowel or Vagina or usually affect your J, urine rectum Pelvis

I. ability to do household chores (cooking, housecleaning, laundry)? 0 Not at all 0 Not at all 0 Not at all 0 Somewhat 0 Somewhat 0 Somewhat 0 Moderately 0 Moderately 0 Moderately 0 Quite a bit 0 Quite a bit 0 Quite a bit

2. ability to do physical activities such as walki ng, swimming, or other 0 Not at all 0 Not at nil 0 Not at all

exercise? 0 Somewhat 0 Somewhat 0 Somewhat 0 Moderately 0 Moderately O Moderately 0 Quite a bit 0 Quite a bit 0 Quite a bit

3. entertainment activities such as going to a movie or concert? 0 Not at all 0 Not at nil D Not at ni l 0 Somewhat 0 Somewhat 0 Somewhat 0 Moderately 0 Moderately D Moderately 0 Quite a bit 0 Quite a bit O Quiteabit

4. ability to travel by car or bus for a distance greater than 30 minutes 0 Not at all 0 Not at all 0 Not at all

away from home? 0 Somewhat 0 Somewhat 0 Somewhat 0 Moderately D Moderately D Moderately 0 Quite a bit 0 Quite a bit 0 Quite a bit

5. participating in social activities outside your home? 0 Not at all 0 Not ni all D Not at all 0 Somewhat 0 Somewhat 0 Somewhat 0 Moderately 0 Moderately D Moderately 0 Quite a bit 0 Quite a bit 0 Quite a bit

6. emotional health (nervousness, depression, etc.)? 0 Not at all 0 Not at nil 0 Not at all 0 Somewhat 0 Somewhat 0 Somewhat 0 Moderately 0 Moderately D Moderately 0 Quite a bit 0 Quite a bit D Quite a bit

7. feeling frustrated? D Not at all D Not at all D Not at all D Somewhat D Somewhat D Somewhat D Moderately D Moderately D Moderately 0 Quite a bit D Quite a bit 0 Quite a bit

Pelvic Floor Impact Questionnaire - shon form 7 0 Cleveland Clinic Foundation Gynecology

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