Women’s Health Questionnaire Make an Appointment Women's Health Questionnaire Name(Required)Age(Required)Date MM slash DD slash YYYY Describe the current problem that brought you here?Describe the current problem that brought you here?When did your problem first begin?Month Ago orYear AgoWas your first episode of the problem related to a specific incident? Yes No Please describe and specify dateSince that time is it: staying the Same Getting Worse Getting Better Why or how?Why or how?Describe the nature of the painIf pain is present rate pain on a 0-10 scale being the worstDescribe previous treatment/excercisesActivities/events that cause or aggravate your symptoms.Check/circle all that apply Sitting greater than With cough/sneeze/straining Walking greater than With laughing/yelling Standing greater than With lifting/bending Changing positions With cold weather Light activity With triggers -running water/key in door Vigorous activity/exercise With nervousness/anxiety Sexual activity No activity affects the problem Other, please list What relieves your symptoms?What are your treatment goals/concerns?How has your lifestyle/quality of life been altered/changed because of this problem? Social activities Diet /Fluid intake Physical activity Work Other Rate the severity of this problem from 0 -10 with 0 being no problem and 10 being the worst.What are your treatment goals/concerns?Since the onset of your current symptoms have you had:Fever/Chills Yes No Malaise Yes No Unexplained weight change Yes No Unexplained muscle weakness Yes No Change in bowel Yes No Numbness / Tingling Yes No Other /describe Yes No Health HistoryNameDate of last physical examTests performedGeneral HealthGeneral Health Excellent Good Average Fair Poor OccupationHours/weekOn disability or leave?Activity Restrictions?Mental HealthCurrent level of stress High Med Low Current psych therapy? Yes No Activity/ExerciseActivity/Exercise None 1-2 days/week 3-4 days/week 5+ days/week DescribeHave you ever had any of the following conditions or diagnoses? circle all that apply Cancer Stroke Emphysema/chronic bronchitis Heart problems Epilepsy/seizures Asthma High Blood Pressure Multiple sclerosis Allergies-list below Ankle swelling Head Injury Latex sensitivity Anemia Osteoporosis Hypothyroid/ Hyperthyroid Low Back Pain Chronic Fatigue Syndrome Headaches Sacroiliac/Tailbone pain Fibromyalgia Diabetes Alcoholism/Drug problem Arthritic conditions IGdney disease Childhood bladder problems Stress fracture Irritable Bowel Syndrome Depression Rheumatoid Arthritis Hepatitis HIV/AIDS Anorexia/bulimia Joint Replacement Sexually transmitted disease Smoking history Bone Fracture Physical or Sexual abuse Vision/eye problems Sports Injuries Raynaud's Hearing loss/problems TMJ/ neck pain Pelvic pain Other/Describe Surgical /Procedure History Yes No Surgery for your back/spine Yes No Surgery for your bladder Yes No Surgery for your brain Yes No Surgery for your bones Yes No Surgery for your female organs Yes No Surgery for your abdominal organs Yes No Other/describeOb/Gyn History (females only)Childbirth vaginal deliveries# Yes No Vaginal dryness Yes No Episiotomy Yes No Painful periods Yes No C-Section Yes No Menopause - when? Yes No Difficult childbirth Yes No Painful vaginal penetration Yes No Prolapse or organ falling out Yes No Pelvic pain Yes No Other/describeMales onlyProstate disorders Yes No Erectile dysfunction Yes No Shy bladder Yes No Painful ejaculation Yes No Pelvic pain Yes No Other/describeMedications Pills Injection Patch Start Date MM slash DD slash YYYY Reason for TakingPelvic Symptom QuestionnaireNameBladder / Bowel Habits / ProblemsTrouble initiating urine stream Yes No Blood in urine Yes No Urinary intermittent Yes No Painful urination Yes No Trouble emptying bladder Yes No Trouble feeling bladder urge Yes No Difficulty stopping urine the stream Yes No Current laxative use Yes No Trouble emptying bladder completely Yes No Trouble feeling bowel/urge/fullness Yes No Straining or pushing to empty bladder Yes No Constipation/straining Yes No Dribbling after urination Yes No Trouble holding back gas Yes No Constant urine leakage Yes No Recurrent bladder infections Yes No Other/describeFrequency of urinationAwake hours times per daySleep hours times per nightWhen you have a normal urge to urinate, how long can you delay before you have to go to the toilet? Minutes Hours Not at All The usual amount of urine passed is: Small Medium Large Frequency of bowel movements:Times per dayTimes per weekWhen you have an urge to have a bowel movement, how long can you delay before you have to go to the toilet? Minutes Hours Not at All If constipation is present describe management techniques.Average fluid intake (one glass is 8 oz or one cup) glasses per dayOf this total how many glasses are caffeinated? glasses per day.Rate a feeling of organ "falling out / prolapse or pelvic heaviness/pressure:None PresentTimes Per MonthWith Standing ForMinutesHoursWith Exertion or StrainingOtherSkip questions if no leakage/incontinenceBladder leakage - number of episodesNo LeakegeTimes Per DayTimes Per WeekTimes Per MonthOnly With Exertion/Strong UrgeBowel leakage - number of episodesNo LeakegeTimes Per DayTimes Per WeekTimes Per MonthOnly With Exertion/Strong UrgeOn average, how much urine do you leak?No LeakegeJust a Few DropsWets UnderwearWets OuterwearWets the FloorHow much stool do you lose?No LeakegeStool StainingSmall Amount in UnderwearComplete EmptyingWets the FloorWhat form of protection do you wear?NoneMinimal protection (Tissue paper/paper towel/pantishields)Moderate protection (absorbent product, maxipad)Maximum protection (Specialty product/diaper)OtherOn average, how many pad/protection changes are required in 24 hours? #of pads Since
