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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.

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