Download WELCOME TO OUR FAMILY - Athena Women`s Institute for Pelvic

Athena Women’s Institute for Pelvic Health
151 Fries Mill Road, Suite 301
Turnersville, NJ 08012
Phone: 856-374-1377
Fax: 856-374-2177
Appointment Details
Name:
Appointment Date:
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Appointment Time:
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Please arrive 30 minutes early for your initial visit in order to get your information into the computer and
prepare you for your visit. There is a $75.00 fee for No-Shows, call within 24 hours if you need to cancel.
Please read, complete and sign the following before arriving to your appointment:
 Partners in Health Agreement
 Patient Registration Form
 Mission Statement Receipt
 Financial Policy
 Insurance Authorization
 Consent for Treatment
 HIPAA / Authorization regarding Medical Information
 Bladder Diary
 Patient History
 Complete ALL questionnaires that apply
*Please bring your completed packet and your insurance card as well as a photo ID*
We also ask that you arrive at your initial appointment with a comfortably full bladder.
Thank you
The staff at Athena Women’s Institute for Pelvic Health
looks forward to being involved in your care.
151 Fries Mill Road ● Suite 301
Turnersville ● NJ ● 08012
ph: (856) 374-1377
fx: (856) 374-2177
www.athena-wmg.com
Timothy B McKinney, MD
Elizabeth Babin, MD
Linda Narcisi APN
Welcome to our family!
Dear Patient,
We intend to provide you with the care and service that you expect and deserve. Achieving your best possible health
requires a partnership between you and your doctor. As our partner in health, we ask you to help us in the following ways:
Be sure your referral paperwork is here the day before your initial appointment:
To avoid being responsible for the entire cost of my visit, I understand that I am responsible for checking with my primary care
physician or insurance company to find out whether or not a referral is necessary for my visit. I will also be sure to check my
insurance card to verify whether or not a copay will be due at the time of my visit. I realize that I am coming to a “specialist office”
and the copay may differ from regular “office visits.”
Keep follow-up appointments and reschedule missed appointments:
I understand that my doctor will want to know how my condition progresses after I leave the office. Returning to my
doctor on time gives him or her the chance to check my condition and my response to treatment. During a follow-up appointment,
my doctor might order tests, refer me to a specialist, prescribe medication, or even discover and treat a serious health condition.
If I miss an appointment and don’t reschedule, I run the risk that my physician will not be able to detect and treat a serious health
condition. I will make every effort to reschedule missed appointments as soon as possible.
Call the office when I do not hear the results of Labs and other tests:
I understand that my physician’s goal is to report my lab and test results to me as soon as possible. However, if I do not hear
from my physician’s office within 2 weeks, I will call the office for my test results. No news is exactly that, I will not assume that
if I do not hear from you that my results are normal.
Inform my doctor if I decide not to follow his or her recommended treatment plan:
I understand that after my examination, my doctor may make certain recommendations based on what he or she feels is best
for my health. For the same reasons it is important to come to my follow up appointments, it is important for me to follow my
treatment plan. I understand that not following my treatment plan can have serious negative effects on my health. I will let my
doctor know whenever I decide not to follow his or her recommendation so that he or she may fully inform me of any risks
associated with my decision to delay or refuse treatment. Finally, I understand the importance of providing a full and complete
medical history. All conditions and symptoms of which I am aware will be disclosed in my medical history questionnaire.
Consent for Off-Label Use of Medication:
Many medications are prescribed routinely for “off-label” used. This means that the medication (or device) is FDA approved,
but the use for which it is being prescribed is not specifically in the package labeling on the Physician’s Desk Reference. Such
prescriptions are extremely common and considered appropriate in the medical profession by the FDA and off-label uses are
part of routine medical practice. I understand that my physician may prescribe an approved medication for an off-label use when
the potential benefits to me outweigh any potential risks, and that any significant risks or alternatives will be explained to me.
Patient Signature__________________________________________________ Date__________________
Patient Name Printed_______________________________________________
151 Fries Mill Road ● Suite 301
Turnersville ● NJ ● 08012
ph: (856) 374-1377
fx: (856) 374-2177
www.athena-wmg.com
Timothy B McKinney, MD
Elizabeth Babin, MD
Linda Narcisi APN
DIRECTIONS TO OUR OFFICE
FROM ROUTE 42 SOUTH:
Follow Rt. 42 South until the fork in the road (to the left is Atlantic City Expressway to the right is where 42 merges with the
Black Horse Pike) stay to the right (which is actually straight on) and follow the Black Horse Pike. Follow the Black Horse
Pike and Fries Mill Road will be on the right hand side. (You can only turn right at this light) Slight right onto Fries Mill Road
and our complex is right before Able Imaging on the right hand side.
FROM WEST BLACK HORSE PIKE:
Head East on Black Horse Pike, follow until Watson Road (there is a Target & a Lowes at this light) make a left. Follow until
the end of the road (Fries Mill Road) Make a right onto Fries Mill Road. The University Executive Campus is down on the left
hand side right after Able Imaging.
FROM ATLANTIC CITY EXPRESSWAY (toward Camden/Philadelphia):
Take the CR-689 exit, EXIT 41, toward Berlin/Cross Keys/Gloucester Twp/Winslow Twp. Turn left at light onto Berlin Cross
Keys Rd/Cross Keys Rd. Berlin Cross Keys Rd/Cross Keys Rd becomes Cross Keys-Berlin Rd. Cross Keys-Berlin Rd
becomes Cross Keys Byp. Turn right onto Hurffville-Crosskeys Rd. If you reach Oak Ridge Ln you've gone too far. Take
the 1st right onto Fries Mill Rd. The University Executive Campus is down on the left hand side right after Able Imaging.
Please Note:
We are the 2nd right turn once in the complex. We are the last building on the left Suite 301.
Timothy B McKinney, MD
Elizabeth Babin, MD
Linda Narcisi APN
151 Fries Mill Road ● Suite 301
Turnersville ● NJ ● 08012
ph: (856) 374-1377
fx: (856) 374-2177
www.athena-wmg.com
Office Policies
Office visits:
•
For your first visit, we recommend that you arrive 30 minutes prior to your scheduled appointment. This will allow for
completion of paper work, insurance verification, and a timely start with your practitioner.
•
Follow up visits it is recommended that you arrive 15 minutes prior to your visit for the same reasoning.
•
We will do our best at providing you with timely medical care. As a specialist, emergencies do occur, which can affect the flow
of your visit. We will do our best to keep you informed of how this may affect your visit. If we run more than one hour behind in
appointments or if we need to be out of the office, you will be notified as soon as possible and given the opportunity to
reschedule your appointment.
•
In addition, we try to give you our undivided attention during your scheduled time. We also want to make sure you are satisfied
with your medical care. Sometimes this might make your appointment run over into someone else’s session. We try to keep
this to a minimum. Please be patient if your time is affected because you too will be given the same opportunity. If your visit is
more complicated and requires more time than scheduled you may be asked to schedule another appointment to address all
of your concerns in a timely manner without affecting another patient’s time.
Routine Care, Simple Bladder Infections:
We are a specialist office treating complicated pelvic conditions. We highly recommend that you have a Primary Health Care
Practitioner/Family Doctor, who will schedule and perform routine testing, lab work, and yearly physical exams. Let your Primary
Physician determine at which point you will need to follow up with a specialist such as our Practitioners. Please follow this policy unless
otherwise notified by our office.
IF HOWEVER YOU ARE A PATIENT WHO SUFFERS FROM CHRONIC OR RECCURING UTI’S, PLEASE CALL OUR OFFICE
WITH QUESTIONS AND DROP OFF A URINE SAMPLE FOR CULTURE ANYTIME SYMPTOMS ARISE.
Late, Cancellations or No Shows:
Because of the number of patients that need to be seen, please be courteous and let us know as soon as possible if you need to
cancel or reschedule your appointment.
Late: If you are more than 15 minutes late for an appointment you will be asked to reschedule your appointment. Repetitive tardiness
may be grounds for dismissal from the practice with 30 days notification.
Cancellations & No Shows: If you cancel with less than 24 hour notification or no show for your scheduled appointment you will be
charged to following fees:
Biofeedback/Physical Therapy
$ 25.00
Office Visits & Consultations
$ 75.00
Testing such as Urodynamic & Cystoscopy $150.00
Procedures/Surgeries
$250.00
Repetitive cancellations and no shows will be grounds for dismissal from the practice with 30 days notification.
Hours of Operation:
Hours are by appointments only. The general office hours are Monday – Friday 8:00am-5:00pm. We do not accept walk-in patients.
Hours may change based on physician availability, surgical schedules, and holidays. For details, please call and speak to our staff.
Appointments are scheduled for evaluations, consultations, testing, treatments and surgery. Please be advised that all questions and
concern should be addressed during your scheduled time.
Phone Call Policy:
Our staff will do their best to address any questions or concerns you may have over the phone. Please be advised that practitioners are
unable to schedule phone consultations. Please make an appointment to review your concerns in person. Lab results can be given
over the phone by a member of our staff with the approval of a practitioner. However, detailed review of these findings may require an
office visit. You will be informed of this when appropriate. Prescriptions and refills will only be addressed during normal business
hours. Please plan ahead for refills, since these will not be addressed after hours. Narcotic prescriptions CAN NOT be called in. These
require evaluation by a practitioner and a written prescription.
Timothy B McKinney, MD
Elizabeth Babin, MD
Linda Narcisi APN
151 Fries Mill Road ● Suite 301
Turnersville ● NJ ● 08012
ph: (856) 374-1377
fx: (856) 374-2177
www.athena-wmg.com
Mission Statement: (See also the receipt of this Mission Statement)
The staff and practitioners at Athena Women’s Institute for Pelvic Health are dedicated to providing you with the most up-to-date
treatment options for your female healthcare needs. We are a “group” medical practice which means we work as a team to provide
excellent care. In our team approach, your appointments will be scheduled at your convenience. We will strive to have you meet as
many of our practitioners as possible. However, we cannot guarantee that you will have the same practitioner at every appointment,
but please be aware that every practitioner is aware of your care and has full access to your medical records.
Athena Women’s Institute for Pelvic Health is a practice specializing in female pelvic medicine, urogynecology, reconstructive surgery
and advanced gynecology. We are considered specialists; therefore this may affect your insurance co-payments and need for
referrals. We highly recommend that you have a primary health care physician for your routine needs.
Mission
Emergency Policy:
•
A practitioner will be on call 24 hours a day for emergencies. Though difficult to fully explain in this small area what constitutes
an emergency, the easiest rule of thumb is to evaluate anything you may consider going to the emergency room or calling 9-11 for. If your concern falls into this category, please call our practitioners or seek appropriate care.
•
Outside of this definition, if your concern can wait until normal business hours, then please address these concerns when the
office is open.
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Surgical patients will be given specific post-operative instructions indicating if and when they should call for emergencies.
Please refer to this paperwork.
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Emergency calls will be returned as soon as possible. If you do not hear from one of our practitioners within one hour, please
call the answering service back, call 9-1-1 or go to the nearest emergency room.
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When calling, PLEASE REMOVE CALL BLOCK FROM YOUR PHONE. IF THIS IS NOT REMOVED OUR PRACTIONERS
WILL NOT BE ABLE TO CALL YOU BACK.
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When calling, please be available to speak to the doctor. The doctor may have questions for you that a family member will not
be capable of answering.
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If you are instructed to go to the emergency room, please do so. We do not make these decisions lightly. Failure to follow such
directions may result in severe consequences to your health.
•
When going to an emergency room, have available all current medications and be able to provide a list of medical conditions
and past surgeries. It is also helpful to have your pharmacy phone number for any prescription needs. The emergency room
physician will be the doctor who will evaluate you. If need be they will contact your practitioner for added instructions,
consultations, and interventions. Please be aware that going to the emergency room or hospital does not guarantee that your
practitioner will be there to see you. Your practitioner will be called into the hospital when medically appropriate.
Concerns that do not meet emergency criteria include but are not limited to:
 Prescription refills
 Appointments cancellations and scheduling
 Lab results
 Birth control
 Sexual Disorders
 Constipation in non-surgical patients
 Temperature less than 100.4
 Pessary fitting or falling out
 Bladder infections
 Vaginal infections
Once again we would like to welcome you to our family. Please feel free to contact us with any further questions or concerns.
You may need to be scheduled for a:
The Urodynamic study is the name given to a number of tests designed to show how your bladder functions. The main test
is called cystometry, which measures your bladder’s ability to store and pass urine.
Why are Urodynamics performed?
Urinary problems, especially incontinence, may affect women of any age. Problems such as these usually increase with
age, pregnancy, childbirth and the onset of menopause.
Your symptoms may include:
 Loss of urine while coughing, sneezing, laughing or exercising
 Sudden and/or frequent urge to pass urine
 Getting up at night frequently to pass urine
 Difficulty in emptying your bladder
 Recurrent bladder infections
Results from urodynamic tests allow your doctor to demonstrate the reason why you have the symptoms you have, and so
offer you the best treatment for your problems.
How is the test performed?
There are several slightly different ways that the Urodynamic testing can be performed, but the principles are the same.
 You may first be asked to do a series of exercises with a full bladder to see how bad your leakage is. This is called
a pad test. Don’t worry, you will not be expected to do anything which you are not normally able to do easily.
 You will then be asked to pass urine into a special toilet to measure how quickly your bladder is able to empty. You
may have a bladder scan immediately after you have passed urine to assess how well your bladder has emptied.
 Following this, a small plastic tube called a catheter will be inserted into your bladder so it can be filled with fluid.
Two fine soft catheters (sensors) will also be inserted, one into the bladder and the other into the vagina or rectum.
These lines will record pressures measured in your bladder and abdomen. The information contained in this
brochure is intended to be used for educational purposes only. It is not intended to be used for the diagnosis or
treatment of any specific medical condition, which should only be done by a qualified physician or other health care
professional.
 During the procedure you will be asked questions about the sensations in your bladder. You will also be asked to do
some of the things which might trigger the problem you have (e.g. cough, strain, jog, stand up, or listen to the sound
of running water). Let the person doing the test know when your bladder feels full.
 Finally, you will be asked to empty your bladder again, with the two fine sensors still in place. The sensors are then
removed and the procedure is complete, and you can get dressed.
Are there any alternatives to Urodynamics?
Not everyone with bladder symptoms will need to have Urodynamics. If simple conservative management such as altering
your fluid intake, exercises and/or medicine fails, then Urodynamics is the best way that your bladder function can be
properly measured, and treatment tailored to your particular problem.
Are there any risks?
No matter how carefully the test is performed urine infections can sometimes occur after it. You should drink more water
than usual for a day or two to flush out any bacteria. You may be advised to take tablets of antibiotics for a short period of
time after the test to prevent infection.
What to expect afterwards?
Passing urine may sting a little for a day after the test, but if you think that you have developed a urine infection please let
your doctor know.
You may need to be scheduled for a:
What is a Cystoscopy?
Cystoscopy is the name for a procedure allowing a doctor to look into your bladder and urethra with a special scope called a
cystoscope. When you have a bladder problem, your doctor may use a cystoscope to see inside your bladder and urethra.
The urethra is the tube that carries urine from the bladder to the outside of the body. This procedure is performed to
Why is a cystoscopy performed?
A cystoscopy may be done to help to find the cause of symptoms such as:
 Loss of bladder control (incontinence) or overactive bladder.
 Frequent bladder infections.
 Blood in the urine (hematuria).
 Unusual cells found in a urine sample.
 Pain in the bladder, urethra or during urination.
The examination is more successful than other tests, like urine tests or ultrasound in picking up problems such as bladder
stones, bleeding, tumors, and structural abnormalities of the bladder.
About the test
 The procedure can be done in the doctors’ office or in the operating room, depending on your symptoms. Your
doctor will recommend where you have your test performed. The test may be performed under a general or local
anesthesia; your doctor will inform you of this before the surgery.
 On average, the test will take 15 to 20 minutes to complete.
 You may be asked to change into a hospital gown for the procedure, and the lower part of your body will then be
covered with a sterile drape. In most cases you will lie on your back with your knees raised and apart. The area
around your urethra will be cleaned and numbing jelly (local anesthesia) may be applied to the urethra.
 The doctor will then gently insert the cystoscope into your bladder. When the camera is inserted it may be a little
uncomfortable, relaxing the pelvic floor muscles will make this part of the test easier. Most women tolerate the test
very well.
 The doctor will fill your bladder with a sterile liquid to allow a good view of the bladder wall. As your bladder fills you
may feel an urge to urinate and some mild discomfort in the bladder. You will be able to empty the bladder as soon
as the examination is over.
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Are there any risks?
The risks of complications with this procedure are low, they include:
 urinary tract infection
 bleeding
 injury to the bladder or urethra
What to expect afterwards?
You may have some temporary mild burning feeling when you urinate, and you may see small amounts of blood in your
urine. A warm bath or the application of a warm damp washcloth over your urethral opening may relieve the burning feeling.
These problems should not last longer than 24 hours.
Date:
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Patient’s Name(First)
Patient’s Social Security Number
Address
City
Telephone Number (Home)
Date of Birth
Marital Status
Patient’s Employer
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APT #
Zip
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Insurance Information: (Copy of Insurance Card Required)
Insurance Company Name
Policy Number
Group Number
Address
Telephone
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Additional information is required if you are not the policy holder
Responsible Party’s Name (First)
(Last)
Responsible Party’s Social Security Number
Address
APT #
City
State
Zip
Telephone Number (Home)
(Cell)
Date of Birth
Age
Responsible Party’s Employer
Address
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Primary Physician
Physician’s Name
Address
Phone #
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Referring Physician
Physician’s Name
Address
Pharmacy
Pharmacy Name
Address
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How were you referred to our practice:
o PCP
o OB/Gyn
o Friend/Relative
o Yellow Pages
Patient’s Signature
o Advertisement
o Internet
o Other (explain)
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I
have read and I understand the Mission Statement and Policies of
Athena Women’s Institute for Pelvic Health and I received a copy of this document. At any point in time, I
may request an additional copy of this statement, and will be notified of any policy changes.
Patient Signature________________________________________________ Date________________
Dr. Elizabeth Babin, MD
Dr. Timothy McKinney, MD
Linda Narcisi, RN,APN
151 Fries Mill Road ● Suite 301
Turnersville ● NJ ● 08012
ph: (856) 374-1377
fx: (856) 374-2177
www.athena-wmg.com
Timothy B McKinney, MD
Elizabeth Babin, MD
Linda Narcisi APN
OUR FINANCIAL POLICY
We consider our fees to be reasonable and customary for this area. We are also aware that your insurance
company may have its own reasonable and customary scale; however, unless we have a signed contract with
your carrier, you are responsible for any balance.
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If your insurance is an HMO, PPO, or a form of managed care, and referrals are required, you must
obtain a referral form from your primary physician for any specialty services. Without the proper referral,
you will be responsible for payment of these services. It is the patient’s responsibility to know the
policies and procedures of their medical insurance company.
ALL PATIENTS are responsible for their deductibles, co-pays, and balances. Co-pays must be paid at
the time of service.
MEDICARE PATIENTS are responsible for their deductibles and the 20% of Medicare’s approved
amount that is not paid by Medicare.
We will file you insurance claims for you; however, you must be aware that your contract is with your
insurance company, and it is ultimately your responsibility to see that we receive payment for services.
If we have not received payment from your insurance carrier within 60 days of filing, you are
responsible for payment.
All balances are due within 30 days of insurance payments.
Cancellations & No Shows: If you cancel with less than 24 hour notification or no show for your
scheduled appointment you will be charged to following fees:
•Biofeedback/Physical Therapy
$ 25.00
•Office Visits & Consultations
$ 75.00
•Testing such as Urodynamic & Cystoscopy
$150.00
•Procedures/Surgeries
$250.00
Repetitive cancellations and no shows will be grounds for dismissal from the practice with 30 days
notification.
For all surgery patients, all non-covered or out of pocket portion of the insurance policy will be
collected prior to the date of surgery. The deposit will be an estimate of patients' responsibility NOT
COVERED by your Insurance Policy. This portion is based on surgery cost and/or the deductible. The
scheduling of a surgery requires an extensive amount of time and paperwork. For this reason, a $250
non-refundable charge will be applied if surgery is cancelled without reason or acceptable advance
notice.
Processing of disability documents are charged at a fee of $25.00 per event.
A personal copy of medical records is available and charged at a fee of $25.00. If medical records are
requested for continuing care, we will be happy to fax them directly to a physician at no charge.
We accept cash, checks, credit cards such as MasterCard, Visa, Discover and American Express
I HAVE READ AND UNDERSTAND AND AGREE WITH THE ABOVE.
______________________________________
Patient and/or responsible party’s signature
Dr. Elizabeth Babin, MD
Dr. Timothy McKinney, MD
____________________
Date
Linda Narcisi, RN,APN
On this form we require a
SIGNATURE ONLY
this authorizes us to bill your
insurance company. Please date the form as well. (Next to the stars)
151 Fries Mill Road ● Suite 301
Turnersville ● NJ ● 08012
ph: (856) 374-1377
fx: (856) 374-2177
www.athena-wmg.com
Timothy B McKinney, MD
Elizabeth Babin, MD
Linda Narcisi APN
CONSENT FOR TREATMENT: The understanding grants authorization to the physicians, associates, and staff at Athena
Women’s Institute for Pelvic Health for such treatment and procedures that may be necessary for the patient herein
named in accordance with the judgment of the physician. The undersigned acknowledges that no guarantees have been
made as to the results of treatment or examinations in the office, or otherwise.
I realize that I have the right to refuse any drugs, treatment, or procedures to the extent permitted by law.
AUTHORITY TO REVIEW AND RELEASE RECORDS AND INFORMATION:
The undersigned herby authorizes and requests the physicians, associates, and staff of Athena Women’s Institute for
Pelvic Health to furnish and release upon written request to all insurance companies or their representatives insuring the
patient named, to Athena Women’s Institute for Pelvic Health and to any specific person herein named below, any and all
information with respect to the patient herein named including, but not limited to, the case history, examination, prognosis,
treatment medication, x-rays or surgery. Billing agencies which provide specialized services, routinely will receive
information necessary for billing purposed. Medical records may also be used for educational or research purposes with
the patient protected. Authorization is hereby given to physicians, associates, and staff at Athena Women’s Institute for
Pelvic Health to release patient’s name, age, sex, and nature of admission and general condition.
RELEASE OF RESPONSIBILITY FOR PERSONAL VALUABLES:
The undersigned understands and hereby releases physicians, associates, and staff at Athena Women’s Institute for
Pelvic Health from any responsibility due to the loss or damage of any valuables that the patient or the undersigned may
keep in their possession in the office or hospital.
PAYMENT GAURANTEE: The undersigned hereby guarantees payment of all fees and charges incurred by patient for
services that may not be covered under the insurance plan of the insured. In the event that the undersigned fails to make
payment as provided herein or agree to alternate payment arrangements deemed satisfactory by Athena Women’s
Institute for Pelvic Health, affirmative collection measures will be initiated. The undersigned agrees to pay all costs of
collections, including fifteen (15%) percent of the unpaid balance as a reasonable attorney’s fee in the event that such
indebtedness is turned over to any attorney for collection.
ASSIGNEMENT OF BENEFITS: I request payment of authorized benefits to Athena Women’s Institute for Pelvic Health
for all services rendered. I authorize any holder of medical or other information about me to release to my insurance
carrier and its agents, any information needed to determine these benefits or benefits for related services.
The undersigned certifies that she has read the forgoing, that it has been fully explained and that she understands the
contents, and hereby agrees to all terms and conditions set forth in the above paragraphs set forth and acknowledges the
receipt of a copy if requested.
Patient Signature
Date of Signature
Signature of Patient Agent or Representative
Relationship to Patient
Witness Signature
Dr. Elizabeth Babin, MD
Dr. Timothy McKinney, MD
Linda Narcisi, RN,APN
151 Fries Mill Road ● Suite 301
Turnersville ● NJ ● 08012
ph: (856) 374-1377
fx: (856) 374-2177
www.athena-wmg.com
Timothy B McKinney, MD
Elizabeth Babin, MD
Linda Narcisi APN
COMMUNICATION WITH FAMILY & OTHERS INVOLVED IN YOUR CARE
(Signed original to be placed in the central medical record and copy to patient)
HIPAA (Health Insurance Portability & Accountability Act)
THIS NOTICE DESCRIBES HOW PERSONAL AND HEALTH INFORMATION ABOUT YOU MAY BE
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT
CAREFULLY.
This notice of Privacy Practices is provided to you pursuant to the Health Insurance Portability & Accountability
Act of 1996 and its implementing regulations (“HIPAA”). It is designed to tell you how we may, under federal
law, use or disclose your Protected Health Information (“PHI”).
I understand that this authorization is voluntary and that I may refuse to sign this authorization. Unless allowed
by law, my refusal to sign will not affect my ability to obtain treatment, and that I may revoke this authorization
at any time by notifying the physician’s office providing the information in writing. However, the revocation will
not be valid if: (a) the physician has taken action in reliance on this authorization; or (b) if this authorization is
obtained as a condition for obtaining insurance coverage, other law provides the insurer with the right to
contest a claim under the policy or the policy itself.
PATIENT NAME: ________ _____________________________________________
DATE OF BIRTH: _____________________________________________________
OFFICE IDENTIFICATION
Athena Women’s Institute for Pelvic Health
151 Fries Mill Rd. Suite 301, Turnersville, NJ 08012
Phone: (856) 374-1377 Fax: (856) 374-2177
Please list any family members, physicians or others who may be involved in coordinating your care or
payment for care. Also, indicate what information may be shared with each individual.
• Name:__________________________________Relationship to patient:____________________
Type of information:
o All
o Scheduling/Appointment
o Medical Billing/Insurance
• Name:__________________________________Relationship to patient:____________________
Type of information:
o All
o Scheduling/Appointment
o Medical Billing/Insurance
• Name:__________________________________Relationship to patient:____________________
Type of information:
o All
o Scheduling/Appointment
o Medical Billing/Insurance
• Name:__________________________________Relationship to patient:____________________
Type of information:
o All
o Scheduling/Appointment
o Medical Billing/Insurance
Specific instructions or limitations:_______________________________________________________
Validation code: _______________________________
(Please give this to any individual who may be involved in coordinating your care or payment for care. They will
be asked to give this code to our staff before we release information over the phone.) We will continue to rely
on the information on this form when communicating with family members or others involved in your care
unless you request changes. Notify our office if you wish to alter the designations above.
Signature of Patient/Representative:________
_ __________________________Date:____________
Relationship to patient:__________________________________________________
151 Fries Mill Road ● Suite 301
Turnersville ● NJ ● 08012
ph: (856) 374-1377
fx: (856) 374-2177
www.athena-wmg.com
Timothy B McKinney, MD
Elizabeth Babin, MD
Linda Narcisi APN
BLADDER DIARY INSTRUCTIONS
Dear Patient,
Prior to your office visit, documenting your voiding patterns provides important information
about your bladder health to Athena Women’s Institute for Pelvic Health. This chart will help
us understand your fluid intake, voiding and urine leakage so that we may come up with the
best plan of care for you.
If you are being seen for frequent voiding or urinary incontinence, please measure your
urinary output as well as your fluid intake during any two 24 hour periods. Please record the
type of fluid (coffee, soda, orange juice, water, etc.). It is not required that these time periods
be consecutive. Use one two-cup measuring cup to measure your urine output. It is also
helpful to use another measuring cup to measure your fluid intake.
Starting with your first morning void, measure your urine output and note the time and the
amount in your diary. You will continue to mark the time for the remainder of the day,
including voids. The final entry for the first 24 hour period will be the one prior to your next
morning void. Follow the same instructions for the next twenty-four-hour documentation
period that you choose.
Please be sure to document any discomfort such as burning, spasms, fullness, pain, etc.
Should you have an accident, estimate the amount of urine lost as small, medium or large
amount. Please indicate the activity at the time of the incontinence incident such as
laughing, sneezing, walking, coughing, during sex, running to the bathroom, etc.
If you have any questions, please feel free to contact our office 856-374-1377
151 Fries Mill Road ● Suite 301
Turnersville ● NJ ● 08012
ph: (856) 374-1377
fx: (856) 374-2177
www.athena-wmg.com
Timothy B McKinney, MD
Elizabeth Babin, MD
Linda Narcisi APN
BLADDER DIARY
Patient Name:
Date of Birth:
Day 1 Date:
REASON FOR
ACCIDENT
16 ounces
LEAK: SMALL,
MEDIUM,LARGE
CONTINUOUS
M
2 ounces
L,C
On way to bathroom
TIME
AMOUNT
VOIDED
Example 1
Example 2
.
AMOUNTS &
TYPE OF
FLUID DRANK
Coughing
8 ounces coffee
6 am - 7am
7 am - 8 am
8 am - 9 am
9 am - 10 am
10 am - 11 am
11 am - 12 pm
12 pm - 1 pm
1 pm - 2 pm
2 pm - 3 pm
3 pm - 4 pm
4 pm - 5 pm
5 pm - 6 pm
7 pm - 8 pm
8 pm - 9 pm
9 pm - 10 pm
10 pm - 11 pm
11 pm - 12 am
12 am - 1 am
1 am - 2 am
2 am - 3 am
3 am - 4 am
4 am - 5 am
5 am - 6 am
Number of pads or undergarments used today?
Number of accidents today?
Total amount urinated today?
Number of times you urinated during awake hours today?
. Number of times you urinated during sleeping hours today?
.
.
.
151 Fries Mill Road ● Suite 301
Turnersville ● NJ ● 08012
ph: (856) 374-1377
fx: (856) 374-2177
www.athena-wmg.com
Timothy B McKinney, MD
Elizabeth Babin, MD
Linda Narcisi APN
BLADDER DIARY
Patient Name:
Date of Birth:
Day 2 Date:
REASON FOR
ACCIDENT
16 ounces
LEAK: SMALL,
MEDIUM,LARGE
CONTINUOUS
M
2 ounces
L,C
On way to bathroom
TIME
AMOUNT
VOIDED
Example 1
Example 2
.
AMOUNTS &
TYPE OF
FLUID DRANK
Coughing
8 ounces coffee
6 am - 7am
7 am - 8 am
8 am - 9 am
9 am - 10 am
10 am - 11 am
11 am - 12 pm
12 pm - 1 pm
1 pm - 2 pm
2 pm - 3 pm
3 pm - 4 pm
4 pm - 5 pm
5 pm - 6 pm
7 pm - 8 pm
8 pm - 9 pm
9 pm - 10 pm
10 pm - 11 pm
11 pm - 12 am
12 am - 1 am
1 am - 2 am
2 am - 3 am
3 am - 4 am
4 am - 5 am
5 am - 6 am
Number of pads or undergarments used today?
Number of accidents today?
Total amount urinated today?
Number of times you urinated during awake hours today?
. Number of times you urinated during sleeping hours today?
.
.
.
Patient General History
Patient Name: _______________________________________ Age: ______ Date of Visit____________________
Your answers to the following questions will help us understand your medical condition better. If you cannot remember specific details,
your estimates will be fine. If you need extra room for anything, please use the back of this paper.
By what name do you prefer to be called?_________________________________________
What is your current occupation?________________________________________________
Who referred you to our practice?________________________________________________
Who are your Primary care physicians and general OB/GYN?__________________________
Which doctor would you like to receive our records?__________________________________
How would you rate your general health: 
Excellent 
Good
Fair
Poor
*Please describe the reason for your visit today_________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Please list any chronic medical conditions for which you have a diagnosis of or see a doctor for:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Surgical History:
Have you had any prior surgeries? YES NO
Surgery:
Date:
151 Fries Mill Road ● Suite 301
Turnersville ● NJ ● 08012
ph: (856) 374-1377
fx: (856) 374-2177
www.athena-wmg.com
Timothy B McKinney, MD
Elizabeth Babin, MD
Linda Narcisi APN
Allergies:
Do you have any allergies to medication? YES NO
If yes, please list the medication and reaction below:
Medication allergic to:
Are you allergic to:
 Latex
 X-Ray Dye
 Other:
Reaction:
.
Medications:
Are you currently taking any prescription or non-prescription drugs? Yes No
Please list in the spaces below, all current prescription and non-prescription drugs you are taking:
Medication:
Dose (mg/pills)
and times per day:
Reason:
151 Fries Mill Road ● Suite 301
Turnersville ● NJ ● 08012
ph: (856) 374-1377
fx: (856) 374-2177
www.athena-wmg.com
Timothy B McKinney, MD
Elizabeth Babin, MD
Linda Narcisi APN
Obstetrical History:
Please list any pregnancies or miscarriages:
Delivery Date
Hospital
Vaginal/
C-Section
Hours in
Labor
Weight
Sex
Forceps
Vacuum
Episiotomy
Large Tear?
Gynecologic History:
If menopausal, you may skip menstrual cycle questions:
First day of your last
period?
Are your periods
normal?
Date of last pap?
Date of last
mammogram?
History of vaginal
infection or STD?
Are you sexually
active?
Male-Female -Both
Are you using birth
control?
Number of days of flow?
Is your flow light, medium
or heavy?
Abnormal paps?
Dysplasia or HPV?
Number of days
between periods?
Cramping?
Mild/ Severe?
List any procedures
for abnormal Pap?
Type of infection?
Problems with sexual
activity? (Lack of drive/
orgasm/pain)
Type of birth control?
Have you tried any
treatments?
Family History:
Please list medical conditions/cancers running in your family and in whom:
Family Member:
Condition/Diagnosis:
Complications
151 Fries Mill Road ● Suite 301
Turnersville ● NJ ● 08012
ph: (856) 374-1377
fx: (856) 374-2177
www.athena-wmg.com
Timothy B McKinney, MD
Elizabeth Babin, MD
Linda Narcisi APN
Social History Questions
Do you smoke?
o Never
o Yes: Packs per day? ______
o Quit: What year _______

Do you drink alcohol?
o No
o Yes: Drinks/week
.
Caffeine Intake?
o None
o Coffee/Tea: cups/Day
.
How do you rate your diet?
o Good
o Fair
o Poor
Do you exercise regularly?
o
o
Yes
No
Satisfied with weight?
o
o
Yes
No
Does your job require heavy lifting >20 lbs. on a regular basis?
o
o
Yes
No
Does the use of caffeine, alcohol, or tobacco affect your bladder?
o
o
o
o
o
Yes
No
Caffeine
Alcohol
Tobacco
Have you ever been abused?
o
o
Yes
No
Is violence at home a concern?
o
o
Yes
No
Thank you for taking the time to fill out these questionnaires. We apologize if some of the information seems
redundant. These are questionnaires that help us give a meaningful score to your condition and severity. They
help all of us monitor your progress as well. If the title of the questionnaire does not pertain to your specific
complaint, you may skip it or right N/A.
For each question below, please circle the answer that best describes how you feel. The last 2 columns on the
right are for your doctor to assess your score please do not mark anything in the last 2 columns. Be sure to
bring this questionnaire with you into the examination room so that you can review your answers with the
physician.
Patient Name:
Age:
Date:
.
151 Fries Mill Road ● Suite 301
Turnersville ● NJ ● 08012
ph: (856) 374-1377
fx: (856) 374-2177
www.athena-wmg.com
Timothy B McKinney, MD
Elizabeth Babin, MD
Linda Narcisi APN
HISTORY OF PRESENT ILLNESS: True or False
Patient Name:
Age:
T
T
F
I leak urine. If true, for how long
.
Date:
.
F
I leak urine with sexual intercourse.
I have to wear pads because of losing urine.
If so, how many do you use a day? _______
I often feel the urge and need to urinate even
when my bladder is not very full.
My bladder problem is bad enough that I
would request surgery to fix it.
I have had an operation on my bladder. If
true, how was the operation was performed?
Abdominally or Vaginally
The sound, sight, or feel of running water
gives me the urge to urinate.
The operation I had on my bladder cured my
problem.
The operation I had on my bladder helped my
problem for a time.
If true, for how long did it help?
.
If I suddenly stand up after sitting or lying
down, I lose urine.
I am not aware that I am losing urine until I
notice I am wet.
I urinate more than 8 times a day.
The operation I had on my bladder did not
help at all.
The need to urinate routinely wakes me up at
least two times during the night.
I leak urine when I cough, sneeze, exercise
or move suddenly.
There is blood in my urine.
I lose urine in small spurts.
I have had two or more bladder infections in
the last year.
I lose large amounts of urine and once the
leakage begins I cannot control it.
Intercourse causes me to have bladder
infections.
If I cough hard, I leak at the same time.
I have pain in the area of my bladder.
If I cough hard, the leaking comes a few
seconds later.
It hurts to urinate.
I have trouble starting my urine stream.
I have been treated by urethral dilatation.
My urine stream is no more than a dribble.
I had trouble wetting the bed as a child.
It takes me a long time to empty my bladder.
I have trouble wetting the bed now.
After I urinate, I often feel I have not
completely emptied.
My urine loss is a continual drip, I am
always wet.
151 Fries Mill Road ● Suite 301
Turnersville ● NJ ● 08012
ph: (856) 374-1377
fx: (856) 374-2177
www.athena-wmg.com
Timothy B McKinney, MD
Elizabeth Babin, MD
Linda Narcisi APN
Pelvic Floor Symptoms
Patient Name:
Age:
Date:
.
How often are you troubled with soiling yourself with solid bowel movement?
Never
Less than 2 times/month
2 or more times/month
How often are you troubled with soiling yourself with loose bowel movement?
Never
Less than 2 times/month
2 or more times/month
How often are you constipated?
Never
Less than 2 times/month
2 or more times/month
How often do you have to bear down very hard to empty your bowels?
Never
Up to 25% of the time
Up to 50% of the time
Up to 75% of the time
Up to 100% of the time
How often do you feel that your bowels are not completely empty?
Never
Up to 25% of the time
Up to 50% of the time
Up to 75% of the time
Up to 100% of the time
How often do you have to use your hands or fingers to help empty out your bowel?
Never
Up to 25% of the time
Up to 50% of the time
Up to 75% of the time
Up to 100% of the time
How often do you find small amounts of smearing on your underwear?
Never
Up to 25% of the time
Up to 50% of the time
Up to 75% of the time
Up to 100% of the time
Do you usually have a bulge or something falling out that you can see or feel in the vaginal area?
Yes
No
If yes, how much does it bother you?
Not at all
Somewhat
Moderately
Quite a bit
Do you usually feel a heaviness or dullness in the pelvic area?
Yes
No
If yes, how much does it bother you?
Not at all
Somewhat
Moderately
Quite a bit
Do you ever have to push up on a bulge in the vaginal area with your fingers to start or complete urination?
Yes
No
If yes, how much does it bother you?
Not at all
Somewhat
Moderately
Quite a bit
Y
Do you frequently pass gas when you don't want to?
Do you have a bowel movement at least twice a week?
Are you troubled with hemorrhoids?
Have you recently had a significant change in your bowel habits?
Has the size or caliber of your stool recently changed?
Have you recently had any black or "tarry" stools?
Have you recently had any bright red bleeding with bowel movements?
Are your bowel movements painful?
N
Visual Analog Scales
Patient Name:
Age:
Date:
.
On the scores below, please mark how much of the time you are bothered by:
URGENCY:
Never
All the time
0---------------------------------------------------------5----------------------------------------------------------10
VAS Score
.
FREQUENCY:
Never
All the time
0---------------------------------------------------------5----------------------------------------------------------10
VAS Score
.
PROTRUDING ORGANS/PROLAPSE:
Never
All the time
0---------------------------------------------------------5----------------------------------------------------------10
VAS Score
.
BLADDER OR PELVIC PAIN:
Never
All the time
0---------------------------------------------------------5----------------------------------------------------------10
VAS Score
.
PAIN WITH BOWEL MOVEMENTS:
Never
All the time
0---------------------------------------------------------5----------------------------------------------------------10
VAS Score
.
CONSTIPATION:
Never
All the time
0---------------------------------------------------------5----------------------------------------------------------10
VAS Score
.
PAIN WITH SEXUAL ACTIVITY:
Never
All the time
0---------------------------------------------------------5----------------------------------------------------------10
VAS Score
.
INCONTINENCE:
Never
All the time
0---------------------------------------------------------5----------------------------------------------------------10
VAS Score
.
151 Fries Mill Road ● Suite 301
Turnersville ● NJ ● 08012
ph: (856) 374-1377
fx: (856) 374-2177
www.athena-wmg.com
Timothy B McKinney, MD
Elizabeth Babin, MD
Linda Narcisi APN
Incontinence Impact Questionnaire
Patient Name:
Age:
Date:
.
Some women find that bladder, bowel, or vaginal symptoms may affect their activities, relationships,
and feelings. The questions below refer to areas in your life that may have been influenced or
changed by your problem. For each question, check the box that best describes how much your
activities, relationships, and feelings are being affected by these symptoms.
How do symptoms or conditions related to the following usually affect your:
Bladder or Urine
Bowel or Rectum
Vagina or Pelvis
Bulges
1. Ability to do household chores?
(cooking, housecleaning, laundry)
Not at all
Not at all
Not at all
Somewhat
Moderately
Greatly
Somewhat
Moderately
Greatly
Somewhat
Moderately
Greatly
2. Ability to do physical activities such as walking,
swimming, or other exercise?
Not at all
Not at all
Not at all
Somewhat
Moderately
Greatly
Somewhat
Moderately
Greatly
Somewhat
Moderately
Greatly
3. Entertainment activities such as going to a movie
or concert?
Not at all
Not at all
Not at all
Somewhat
Moderately
Greatly
Somewhat
Moderately
Greatly
Somewhat
Moderately
Greatly
4. Ability to travel by car or bus for a distance
greater than 30 minutes away from home?
Not at all
Not at all
Not at all
Somewhat
Moderately
Greatly
Somewhat
Moderately
Greatly
Somewhat
Moderately
Greatly
5. Participating in social activities outside your
home?
Not at all
Not at all
Not at all
Somewhat
Moderately
Greatly
Somewhat
Moderately
Greatly
Somewhat
Moderately
Greatly
6. Emotional health (nervousness, depression, etc.)?
Not at all
Not at all
Not at all
Somewhat
Moderately
Greatly
Somewhat
Moderately
Greatly
Somewhat
Moderately
Greatly
Not at all
Not at all
Not at all
Somewhat
Moderately
Greatly
Somewhat
Moderately
Greatly
Somewhat
Moderately
Greatly
7. Feeling frustrated?
Athena Women’s Institute for Pelvic Health
REVIEW OF SYSTEMS
Patient’s Name:
Date:
.
Have you had any problems related to the following symptoms in the past 30 days? Circle Yes or No
General
Weight Loss
Weight Gain
Fatigue
Chills
Fever
Trouble Sleeping
Skin
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
Y
Y
Y
Y
N
N
N
N
Ears
Hearing Loss
Pain
Discharge
Ringing in ears
Heart Attacks
Leg Pain with activity
Palpitations
Swelling in legs
Chest Tightness
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
Y
Y
Y
Y
N
N
N
N
Vascular
Calf pain walking
Aortic aneurysm
Leg Cramps
Stroke
Vision Changes
Glaucoma
Blurry Vision
Cataracts
N
N
N
N
Hoarseness
Dry Mouth
Sore Throat
Thrush
Non-healing Sores
Bleeding Gums
Heart Burn
Abdominal Pain
Constipation
Difficulty Swallowing
Blood in Stool
Nausea/Vomiting
Change in bowel
Diarrhea
Jaundice
Hiatal Hernia
Lumps
Pain
Discharge
Breast Feeding
Last Mammogram:
Dizziness
Fainting
Seizures
Tingling/Numbness
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
.
Y
Y
Y
Y
Shortness of breath
Y
Wheezing
Y
List any chronic conditions:
N
N
N
N
N
N
Pain with sex
Heavy menses
Itching or rash
Prior ovarian cysts
Interstitial cystitis
Vaginal dryness
Hot flashes
STD’s
Fibroids
Discharge
Endometriosis
Date of last pap:
N
N
N
N
N
N
N
N
N
N
N
.
Genital
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
Y
Y
Y
Y
N
N
N
Y
Y
Y
Y
N
N
N
N
Heat/cold intolerance Y
Sweating
Diabetes
Thirst
Appetite changes
Frequent Urination
Y
Y
Y
Y
Coughing up blood
Asthma
Cough (dry or wet)
Gasping for air
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
.
Musculoskeletal
Muscle or joint pain
Stiffness
Back pain
Redness of joints
Trauma
Swelling of joints
N
Y
Y
Y
Y
Y
Y
COMMENTS
.
.
.
.
Endocrine
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
Respiratory
Hematologic
Ease of bruising
Ease of bleeding
Blood Clots
Swollen lymph glands
Y
Y
Y
Y
Y
Y
Breasts
Neurologic
Psychiatric
Nervousness
Depression
Memory Loss
Stress
Confusion
Alcohol/Drug Use
Y
Y
Y
Y
Headache
Swollen Glands
Head Injury
Pain
Seizures Ever
Stiffness
Gastrointestinal
Urinary
Frequency
Change in stream
Leakage with cough
Leakage with urge
Blood in Urine
Burning/Pain
Urgency
Bathroom all night
N
N
N
N
N
N
Throat
Cardiovascular
Chest Pain/Pressure
Head/Neck
Y
Y
Y
Y
Y
Y
Eyes
Nose
Stuffiness
Discharge
Itching
Hay Fever
Nose Bleeds
Sinus pain
Dryness
Rashes
Lumps/growths
Itching
Color Changes
Hair/Nail Changes
N
N
N
N
N
N
Patient Signature:
.
N
N
N
N
N
N
.
.
.
.
.