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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: . Appointment Time: . 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. • Surgical patients will be given specific post-operative instructions indicating if and when they should call for emergencies. Please refer to this paperwork. • 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. • When calling, PLEASE REMOVE CALL BLOCK FROM YOUR PHONE. IF THIS IS NOT REMOVED OUR PRACTIONERS WILL NOT BE ABLE TO CALL YOU BACK. • 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. • 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. 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: . Patient’s Name(First) Patient’s Social Security Number Address City Telephone Number (Home) Date of Birth Marital Status Patient’s Employer Address Number (Last) (MI) . . . . . . . APT # Zip State (Cell) Age . . . Insurance Information: (Copy of Insurance Card Required) Insurance Company Name Policy Number Group Number Address Telephone . . . 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 Number . . . . . . . . . Primary Physician Physician’s Name Address Phone # . . Phone # . . Phone/Fax # . Referring Physician Physician’s Name Address Pharmacy Pharmacy Name Address . 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) . . . 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. 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 . . . . .