BIOGRAPHIC INFORMATION REFERRAL INFORMATION
Referring Doctor or Nurse and Address/Phone
Primary Doctor or Nurse and Address/Phone
In order to understand the nature of your pelvic floor concerns more clearly, we ask that you please answer the following questions. Each question tries to uncover specific aspects of incontinence or pelvic prolapse, and will help us make a diagnosis and treatment plan. Section 1: 1. When I need to urinate, I experience an urgency so intense that I must rush to the toilet:
No (if no, go to question 6)
How long have you experienced leakage of urine?
3. I leak urine when I do the following things (check all that apply):
4. I leak urine when I do the following things (check all that apply):
rush to the toilet when I have a strong urge to urinate
SYMPTOM QUESTIONNAIRE CONTINUED Often Half time Rarely Never
My bladder awakens me at night to urinate.
When I am finished urinating, my bladder feels
I need to push hard to empty my bladder.
I feel as if there is something bulging into my
I experience pelvic discomfort when standing or
I have to push on the vaginal walls to empty my
I feel an urge when I need to have a bowel
When I need to have a bowel movement, the
urge is so intense that I must rush to the toilet.
I often have the urge to have a bowel movement
I feel that having a bowel movement does not
I use my fingers in my vagina or rectum to help
If I have to pass gas, I can hold it for a short
Stool comes out when I am not on the toilet.
In my life, I have been sexually or physically
If yes, this has affected my sexual interest.
I have other questions about sexual intercourse.
OTHER SYMPTOMS Currently you are having problems with (check symptoms): General: Ears,nose,throat: Cardiovascular: Respiratory: Gastrointestinal: Musculoskeletal: Emotional: Endocrine: Hematologic: OBSTETRIC AND GYNECOLOGIC HISTORY
During your deliveries, did you ever have a tear into the rectum?
If yes, are you taking hormone replacement?
Are you having problems with your periods?
Date of last colon screening (colonoscopy/sigmoidoscopy)
List all surgeries and the approximate dates: Surgery:
Do you have a history of any of these conditions?
What medications are you currently taking? (Please include all over the counter medicines, herbs, remedies, and supplements.) Medication
List any medications that you are allergic to: Latex allergy?
Medications you have used in the past to control incontinence:
Please note if you have a family history of any of these diseases:
Who is your main support person (partner/spouse/friend)?
How many glasses of beer, wine, or other alcohol do you drink per day?
How many caffeinated beverages (coffee, tea, soda) do you drink per day?
Get regular aerobic exercise such as jogging and aerobics
Able to do aerobic exercise but do not do it regularly
Some women find that accidental urine loss and/or prolapse (falling or dropping of the uterus, vagina, bladder, or bowels) may affect their activities, relationships, and feelings. The questions below refer to areas in your life which may have been influenced or changed by your problem. For each question, check the response that best describes how much your activities, relationships, and feelings are being affected by urine leakage and/or prolapse. Has urine leakage and/or prolapse affected your:
Not at all Slightly Moderately
Physical recreation such as walking, swimming, or other
Entertainment activities (movies, concerts, etc.)?
Ability to travel by car or bus more than 30 minutes from
Participation in social activities outside your home?
Emotional health (nervousness, depression, etc.)?
DAILY ACTIVITIES CONTINUED
The following symptoms have been described by women who experience accidental urine loss and/or prolapse. Please indicate which symptoms you are now experiencing, and how bothersome they are for you. Be sure to answer all questions by checking the appropriate space which best describes how you feel. Do you experience, and if so, how much are you bothered by:
Not at all Slightly Moderately
Urine leakage related to the feeling of urgency?
Urine leakage related to physical activity, coughing, or
Pain or discomfort in the lower abdominal or genital area?
A feeling of bulging or protrusion in the vaginal area?
Bulging or protrusion you can see in the vaginal area?
Having to push on the vaginal walls with your fingers to
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