Download NEW PATIENT SYMPTOM ASSESSMENT – URO/GYNECOLOGY

NEW PATIENT SYMPTOM ASSESSMENT – URO/GYNECOLOGY
Las Name _______________________First Name _____________________Date of Birth_______________
Referring Clinician (if applicable) ____________________________________________________________
Allergies _______________________________________________________________________________
Favorite Pharmacy _______________________________________________________________________
Current Prescription Medications:
Name
Dose (How much?)
Frequency (How often?)
How many times have you been pregnant? _______
How many children have you had? _______
How many vaginal deliveries did you have? _______
Past Medical History
□ High blood pressure
□ Diabetes (what is your hemoglobin A1c? _______%)
□ Blood disorder- clotting problem OR bleeding problem.
□ Heart disease.
□ Other (Please write in) ________________________________
Past Surgery History
□ Removal of uterus.
When (Date)? _____________
□ Removal of ovaries.
When (Date)?_____________
□ Other surgery (Please write in) __________________________
Social History
Occupation________________________________.
□ Tobacco use-smoke, chew, snuff.
□ More than 1 alcoholic beverage per day.
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D1. What is the reason for your visit? (Check all that apply)
□ Accidental bladder leakage
□ Vaginal bulging (vaginal prolapse)
□ Accidental bowel leakage
□ Problems emptying your bladder
□ Problems with emptying your bowels
□ Pain related to your bladder, bowel or pelvic organs
Other:
□ Recurrent bladder infections
□ Problems with the vulva (e.g. pain, itch, skin problem) or Painful intercourse
□ Complication of previous pelvic surgery
□ Not listed? ( Please write in)
____________________________
D2. How long have you had your symptoms? (Choose one best response)
□ ≤ 2 weeks
□ 3-4 weeks
□ 5-8 weeks
□ 9-12 weeks
□ 4-6 months
□ 7-12 months
□ 1-2 years
□ 2-3 years
□ >5 years
D3. How many different clinicians have you seen for your problem? (Choose one best response)
□1
□2
□3
□4
□ 5 or more
D4. Which kind of health care providers have you seen for your problem? (Check all that apply)
□ Primary care provider
□ Physical therapist
□ Urologist
□ Obstetrician/Gynecologist
□ Urogynecologist (subspecialist in Female Pelvic Medicine & Reconstructive Surgery)
□ Pain Management
□ Other
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D5. Among the treatment options listed in the table below which of them have you used for
more than 3 months? (Place a check in any and all boxes that are applicable for the relevant organ or function)
Desired outcome of treatment
Watchful waiting
Treatment Options
Physical Therapy
Pessary
Medications
Surgery
Reduced vaginal budge
Better bladder function
Better bowel function
Restored sexual function
□ I have not tried or considered any treatments for my pelvic floor problems.
Treatment descriptions:
Pessary - A silicon device inserted into the vagina to prop up the vagina.
Physical therapy - Therapist directed exercises to make the pelvic floor muscles stronger
Medications - Oral or topically applied medicines used to improve a pelvic floor function. For example, oxybutynin
(Ditropan) can be used to reduce urge-associated urine leakage or topically applied estrogen cream might help
make exposed vaginal tissues less irritated.
Watchful waiting - Responsibly doing nothing can sometimes be a reasonable approach to some medical
problems. A "cold" doesn't always mean you go to the physician and watchful waiting may be a good approach
to see how the symptoms progress, stabilize or improve. All of these possibilities have been described to
occur for pelvic floor dysfunction.
Surgery - While a major surgical procedure may be imagined to occur for many pelvic floor problems (for
example a hysterectomy). Some surgeries to treat a pelvic floor problem may be small. Example of "small"
pelvic floor surgeries might include injecting medicine into the bladder using a small camera placed in the
bladder or implantation of a small lead along side one of the nerves that go to the bladder. If you went to the
operating room or even a hospital procedure room to get "treated" for pelvic floor problem that could be
considered a surgery.
Readiness to decide?
D6. What is your state of readiness to decide how to treat your pelvic floor problem ? Please mark on the
line below a point that best represents your current readiness to make a decision about your pelvic floor problem.
The line represents a scale between being absolutely sure and absolutely uncertain about how you want to care for
your problem. Your choice may change after you visit with the clinician but we want to know now where you are in
your thoughts.
I know for sure how I
want to treat my
pelvic floor problem
I am completely unsure
how I want to treat my
pelvic floor problem
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Bladder Function
1. How many times do you urinate from the moment you wake until you sleep? _____/day (Write in a whole
number)
2. How many times do you wake from sleep to urinate? _____/night (Write in a whole number)
3. How much caffeine (e.g. coffee, tea, soda) do you consume per day? (Choose one best response)
□ None
□ 1- 2 servings/day
□ 2-4 servings/day
□ >4 servings per day
4. Do you have a history of 3 or more bladder infections in the last 1-year (or 2 or more in the last 6 months)?
(Choose one best response)
□ YES
□ No
5. Have you seen blood in your urine in the last 3 months? (Choose one best response)
□ YES
□ No
6. During the last 3 months, have you leaked urine (even a small amount)?
□ Yes (go to question 7)
□ No (done - no UI skip to question 12)
7. During the last 3 months, did you leak urine: (Check all that apply)
□ When performing some physical activity, such as coughing, sneezing, lifting or exercise?
□ When you had the urge or the feeling that you needed to empty your bladder, but you
could not get to the toilet fast enough?
□ Without physical activity and without a sense of urgency?
8. During the last 3 months, did you leak urine most often: (Choose one best response)
□ When performing some physical activity, such as coughing, sneezing, lifting or exercise?
□ When you had the urge or the feeling that you needed to empty your bladder, but you
could not get to the toilet fast enough?
□ Without physical activity and without a sense of urgency?
□ About equally as often with physical activity as with a sense of urgency?
9. How often do you experience urinary leakage? (Choose one best response)
□ Less than a few times a month (1)
□ A few times a month (2)
□ A few times a week (3)
□ Every day and/or night (4)
10. How much urine do you lose each time? (Choose one best response)
□ Drops (1)
□ Small splashes (2)
□ More (3)
11. How many pads do you use per day? _______/day (Write in a whole number, if not leaking write “0”)
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12. During the last 3 months, has your bladder sensation or function changed during or following urination?
□ No
□ Yes - Check all the symptoms that apply
□ Delay in initiating urination (1)
□ Slow stream (2)
□ Flow stop and start on more than one occasion during a void (3)
□ Straining to void (4)
□ Spraying (5)
□ Feeling of incomplete bladder emptying (6)
□ Need to immediately re-void (7)
□ Post void dribbling (8)
□ Position-dependent voiding (9)
□ Painful urination (10)
□ Inability to pass urine despite persistent effort (11)
13. During the last 3 months, do you usually experience difficulty emptying your bladder?
If ‘yes” how much does it bother you?
□ No (skip to next question)
□Yes
□ Not at all
□ Somewhat
□ Moderately
□ Quite a bit
Pelvic Support
14. During the last 3 months, do you usually have a bulge or something falling out that you can see or feel in
the vaginal area?
If ‘yes” how much does it bother you?
□ No (skip to next question)
□Yes
□ Not at all
□ Somewhat
□ Moderately
□ Quite a bit
15. During the last 3 months, do you usually have to push on the vagina or around the rectum to
have a complete bowel movement?
If ‘yes” how much does it bother you?
□ No (skip to next question)
□Yes
□ Not at all
□ Somewhat
□ Moderately
□ Quite a bit
Bowel Function
16. During the last 3 months, do you feel you need to strain too hard to have a bowel movement?
If "yes" how much does it bother you?
□ No (skip to next question)
□Yes
□ Not at all
□ Somewhat
□ Moderately
□ Quite a bit
17. During the last 3 months, do you feel you have not completely emptied your bowels at the end of a bowel
movement?
If "yes" how much does it bother you?
□ No (skip to next question)
□Yes
□ Not at all
□ Somewhat
□ Moderately
□ Quite a bit
18. During the last 3 months, do you usually lose stool beyond your control if your stool is well formed?
If "yes" how much does it bother you?
□ No (skip to next question)
□Yes
□ Not at all
□ Somewhat
□ Moderately
□ Quite a bit
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19. During the last 3 months, do you usually lose stool beyond your control if you stool is loose or liquid?
If "yes" how much does it bother you?
□ No (skip to next question)
20.
□ Moderately
□ Quite a bit
□Yes
□ Not at all
□ Somewhat
□ Moderately
□ Quite a bit
□Yes
□ Not at all
□ Somewhat
□ Moderately
□ Quite a bit
During the last 3 months, do you experience a strong sense of urgency and have to rush to the bathroom
to have a bowel movement?
If "yes" how much does it bother you?
□ No (skip to next question)
23.
□ Somewhat
During the last 3 months, do you usually have pain when you pass your stool?
If "yes" how much does it bother you?
□ No (skip to next question)
22.
□ Not at all
During the last 3 months, do you usually lose gas from the rectum beyond your control?
If "yes" how much does it bother you?
□ No (skip to next question)
21.
□Yes
□Yes
□ Not at all
□ Somewhat
□ Moderately
□ Quite a bit
During the last 3 months, does part of your rectum ever pass through the rectum and bulge outside
during or after a bowel movement?
If "yes" how much does it bother you?
□ No (skip to next question)
□Yes
□ Not at all
□ Somewhat
□ Moderately
□ Quite a bit
24. How many times do you have a bowel movement each day? _____/day (Write in a whole number)
25. Have you had a colonoscopy? (Choose one best response)
□ YES
□ No
26. Have you seen blood on your stool? ( Choose one best response )
□ YES
□ NO
Sexual Function
27. Which of the following best describes you? ( Choose one best response)
□ Not sexually active at all (Complete question 28 and 30)
□ Sexually active with or without a partner (Complete question 29 and 30)
28. What are the reasons for your NOT being sexually active ( Check all that apply )
□ No partner (to include if partner is unable to have sex)
□ No interest
□ Due to bladder or bowel problems (leakage of urine or stool) or due to pelvic organ prolapse (a
feeling of a bulge in the vaginal area)
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Overall, how bothersome is it to you that you are NOT sexually active?
□ Not at all
□ A little
□ Some
□ A Lot
29. During the last 3 months, do you feel pain during sexual intercourse? (If you don't
intercourse check this box □ and skip to the next item/question)
If "yes" how much does it bother you?
□ No (skip to next question)
□Yes
□ Not at all
□ Somewhat
□ Moderately
□ Quite a bit
30. During the last 3 months, do you feel that your vagina is too loose?
If "yes" how much does it bother you?
□ No (skip to next question)
□Yes
□ Not at all
□ Somewhat
□ Moderately
□ Quite a bit
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Pain Assessment
31. Considering your pelvic area (lower abdomen. vagina. anus. etc) please CIRCLE the words on the
Pain Thermometer that best describe your CURRENT level of pain.
IF HAVING PAIN please MARK on the relevant images where you
are experiencing the pain.
Pain Thermometer Scale
Point lo the words that best
show how bad or severe your
pain is NOW
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