UROGYNECOLOGY New Patient History

MRN: Name: Today's Date

Complaint:

Referring Physician: Primary Care Physician:

Gynecologist: Do you currently see other specialists? Yes No

If yes, list the doctor and specialty:

Medical History - check any and all that apply Anemia High Cholesterol Anxiety HIV Asthma or Emphysema Hypertension Blood clots Kidney Disease - type Bowel Disease - type Liver Disease - type Cancer - type Osteoporosis or Osteopenia Depression Rheumatoid Arthritis Diabetes Stroke Frequent Bronchitis Thyroid Disease - type Glaucoma Other Headaches Heart Burn or reflux Other Heart Disease - type Hepatitis - type Other

Social History

Present amount of tobacco use packs per day Present alcohol intake glasses per week

How long have you been smoking? Prior alcohol use? Yes No Illicit drug use? Yes No Did you smoke in the past? Yes No History of sexual abuse? Yes No If yes, how much? History of domestic abuse? Yes No How many years total? Employment Status:

Marital status: Employed Unemployed Retired Married Single Widowed Occupation:

UROGYNECOLOGY New Patient History 100581 Page 1 of 6 08/19 Fall Risk Assessment

Do you walk unassisted? Yes No Have you fallen in the last year? Yes No

Do you use a cane? Yes No Do you feel unsteady on your feet? Yes No

Do you use a walker? Yes No Do you use a wheelchair? Yes No

Obstetrical and Gynecological History

Age of onset of First Period Year of Last Pap Smear History of Abnormal Pap? Yes No Date of Last menstrual Period History of Hormone Therapy? Yes No Periods: Regular Irregular Oral Patch Vaginal

Heavy or Painful Periods? Yes No History of? Ovarian Cysts Fibroids # of Pregnancies Sexually active? Yes No # of Live births Sexually Transmitted Diseases? Yes No # of Miscarriages

Bleeding with Intercourse? Yes No # of Abortions Largest Birth Weight? Pain with Intercourse? Yes No Circle all that apply: Age at Menopause? History of forceps / Vacuum assisted delivery / Episiotomy / Perineal laceration / Postmenopausal Bleeding? Yes No Birth related pelvic injury

UROGYNECOLOGY New Patient History 100581 Page 2 of 6 08/19 Surgical History

Any History of Pelvic Surgery? Month/Year Procedure

Any History of (Circle all that apply)? Urethral / Bladder / Bowel / Gynecologic Surgery

Month/Year Procedure

History of Hysterectomy?Yes No If yes: Total Partial (Ovaries and tubes conserved)

Month/Year Route (circle) Vaginal / Laparoscopic / Open Abdominal / Robotic

History of Tubal Litigation? Yes No

History of Urological Surgery? (circle) Kidney / Ureter / Bladder / Urethra Month/Year

Procedure

Incontinence Surgery? Yes No Month/Year Procedure

Other Surgery: Month/Year Procedure

Other Surgery: Month/Year Procedure

Other Surgery: Month/Year Procedure

Other Surgery: Month/Year Procedure Family History - Check all that apply

Unknown Cancer - bladder Relation Asthma Relation Cancer - breast Relation Blood Clots Relation Cancer - cervical Relation Diabetes Relation Cancer - colon Relation Heart Disease Relation Cancer - uterine Relation High Cholesterol Relation Cancer - liver Relation Hypertension Relation Cancer - lung Relation Liver Disease Relation Cancer - ovarian Relation Seizures Relation Cancer - pancreatic Relation Stroke Relation Cancer - prostate Relation Thyroid Disorder Relation Cancer - kidney Relation Bleeding Disorder - Type? Relation Cancer - other Relation

Bowel Disease - Type? Relation Cancer - other Relation

UROGYNECOLOGY New Patient History 100581 Page 3 of 6 08/19 REVIEW OF SYSTEMS

Review of systems - please check all that apply

General HEENT Cardiovascular Endocrine Respiratory

Fatigue Headaches Chest Pain Heat/Cold Chills Intolerance Fever Difficulty hearing Fainting spells Cough Weight Gain Ringing in ears Heart Palpitations Loss of hair Coughing up blood Weight Loss Vertigo (dizziness) Murmur Wheezing Vision problems Shortness of breath

Review of systems - please check all that apply

Hematology/Lymph GI GU Musculoskeletal Neurological Easy Bruising Abdominal Pain Blood in Urine Back Pain Headache Enlarged Glands Blood in stool Burning with urination Joint Pain Loss of Strength Gums bleeding easily Constipation Painful Urination Joint Swelling Memory Loss Diarrhea Urine Incontinence Muscle Pain Numbness Fecal Incontinence Vaginal Bleeding Muscle Weakness Tremors Heartburn/Reflux Vaginal Discharge Stiffness Nausea Vomiting

UROGYNECOLOGY New Patient History 100581 Page 4 of 6 08/19 Bladder Habits

# of voids per day # of pads used to stay dry per day

# of times you wake up at night to void # of leaks without activity or sensation

#of episodes of urgency per day Leakage with Intersourse Yes No

# of leaks with urgency per day Bedwetting Yes No

# of leaks with laugh, cough or sneeze # of sugar substitutes used per day per day # of caffeinated drinks per day # of leaks with exercise, lifting, bending over # of carbonated drinks per day Which is more bothersome - leakage with activities or with urge? Or are they equally bothersome? Hesitancy to start urinating Yes No

Straining to maintain flow Yes No

Perform Kegal exercises? Yes No Dribbling after urinating Yes No

Prior pelvic floor rehab or biofeedback? Yes No Urine stream (Circle what applies) Slow / Interrupted / Strong Any prior overactive bladder or bladder control medications: Circle all that apply: Incomplete bladder emptying? Yes No Detrol LA / Ditropan XL / Oxybutynin /

Oxytrol Patch / Sanctura (Trospium) /

Toviaz / Imipramine / Enablex /

Myrbetriq / Vesicare / Flomax /

Estrogen cream

Any help? Yes No

Side effects? Yes No

Which ones?

UROGYNECOLOGY New Patient History 100581 Page 5 of 6 08/19 Bowel Habits

How often do you move your bowels? Circle all that apply: Year of last colonoscopy (if applicable) Daily / Every other day / per week Findings? Bowel Consistency (Circle) Fecal Incontinence? Yes No Formed / Hard / Soft / Loose / Liquid If yes circle all that apply: History of constipation? Yes No Loose / liquid / solid stool / flatus Excessive straining with bowel movement? Yes No How many episodes per week? Incomplete bowel emptying? Yes No Prior Treatment for Incontinence? Yes No Do you use: Circle all that apply: Circle all that apply: Supplemental fiber / stool softeners / laxative Surgery / Fiber / Lomotil / Imodium Prior use of Imodium or Lomotil Yes No Pelvic floor rehab / Biofeedback History of rectal surgery? Yes No Month/year Procedure Bladder / Pelvis Assessment

Lower Urinary Tract Symptoms: Circle all that apply: Pelvic Organ Prolapse: Circle all that apply: Gross Hematuria (Blood in Urine) / Dysuria / Pelvic pressure / Heaviness sensation / Dullness sensation Burning with urination / Pain with full bladder / Vaginal bulge seen or palpable or visible bulge / Urinary odor / Cloudy urine Support to vagina, rectum or perineum to complete a bowel movement or urination Last Urinary Tract Infection? How many Urinary Tract Infection in last 6 months? Prior pessary treatment? Yes No In the last year? If yes, type? Prior antibiotics used? Prolapse Surgery? Yes No Prior long term antibiotics used? Yes No Sexual dysfunction (if sexually active) Suppression for several weeks / months? Pain with intercourse? Yes No Pelvic Pain: Location Pain on entry or deep pain? Yes No Circle all that apply: Sharp / Stabbing / Throbbing / Cramps Urinary incontinence with intercourse? Yes No What makes pain worse? Bowel incontinence with intercourse? Yes No

What makes pain better? Avoidance of sexual relations due to? Circle all that apply: Is pain constant or comes and goes? Pain / Prolapse / Prior treatments: Circle all that apply: Incontinence of urine or bowel / Elavil / Elmiron / Pudendal blocks / Vaginal dryness

Bladder instillation / Neurontin / Narcotics / Lack of interest in sexual intimacy? Yes No NSAIDs / Physical therapy / Pyridium If yes, why? Uribel / Cystoscopy / Hydrodistention / Vaginal Valium / Muscle relaxant

UROGYNECOLOGY New Patient History 100581 Page 6 of 6 08/19