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Women's Pelvic Health and Reconstructive Surgery
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Women's Pelvic Health and Reconstructive Surgery
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Women's Care
Women's Pelvic Health and Reconstructive Surgery
Women's Pelvic Health and Reconstructive Surgery
Women's Pelvic Health and Reconstructive Surgery
Bowel Incontinence
Mesh Complications
Painful Bladder Syndrome (Interstitial cystitis)
Painful Intercourse (Dyspareunia)
Persistent UTI
Pelvic Organ Prolapse
Urinary Incontinence
Main Content
New Patient Form
Name
*
Date of Birth
*
Referring Doctor
*
Primary Doctor
*
What is the main reason for your visit today?
*
Have you been treated for this issue in the past?
*
Yes
No
Year Treated
If Yes, what was your treatment? (i.e. surgery, therapy, pessary, etc.)
What are your goals for today's visit?
*
Preferred Pharmacy
*
Major medical problems now or have had in the past
Abnormal pap
Diabetes
High Blood Pressure
Heart Attack
Thyroid Disorder
Anemia
Migraines
Clotting Disorder
Breast Cancer (CA)
Female Cancer
Kidney Stones
Glaucoma
Irritable Bowel
HIV
Stroke
Hepatitis
Surgeries you have had
*
Hysterectomy
Mesh Sling
Prolapse Repairs
Any abdominal (BELLY) surgeries ( ie: scopes, tubal, C/S, bowel, appendix/gall bladder removal)
Other Surgeries
Is there a family history of
Colon Cancer
Diabetes
Breast Cancer
Female Cancer
Clotting Disorder
Number of pregnancies
*
Any tubal pregnancies
Yes
No
Number of vaginal deliveries
Number of c-sections
Number of miscarriages
Number of abortions
Do you smoke/vape?
*
Yes
No
Packs per day
How many years?
Previously quit?
Yes
No
Do you drink alcohol?
*
Yes
No
If Yes, how often?
Daily
Weekly
Some days but not all
Are you currently using:
Marijuana
Cocaine
Barbiturates
Speed
Heroin
History of emotional, physical or sexual abuse?
*
Yes
No
Are you being abused now?
*
Yes
No
Last Menstrual Period
Length of Flow
How Often
Have you ever had
Gonorrhea
Chlamydia
Trich
Syphilis
Herpes
Sexually active?
*
Yes
No
Is sex painful?
Yes
No
Method of contraception
Do you leak urine?
*
Yes
No
Do you leak stool?
*
Yes
No
If Yes, how long?
Check if you leak with
*
Cough
Laugh
Sneeze
Activity
Sleep
Urge
Which bothers you most
C/L/S Activity
Urge
Equal Bother
Do you wear a pad?
Yes
No
How many do you use during the day?
Overnight?
How many times do you urinate during the day?
During the night?
Bowel movements regular?
*
Yes
No
Constipation
Yes
No
Diarrhea
Yes
No
Do you feel a bulge or falling out in the vaginal area?
*
Yes
No
Do you push with a finger in the vagina to assist with a bowel movement?
Yes
No
Thank you... The form has been submitted.
