{Patient Label} SYMPTOMS SURVEY: FREQUENCY: How many times do you urinate during the day and get up from sleep to urinate at night? Day frequency 3 4 5 6 7 8 9 10 11 12 13 14 15 More Night frequency None 1 2 3 4 5 6 7 8 9 10 URGENCY: Not enough warning before needing to urinate. none mild moderate severe URGE INCONTINENCE: Not able to get there in time. none drops gushes flood STRESS INCONTINENCE: Leaking urine on physical efforts, eg. Coughing, sneezing, lifting. none drops gushes flood WHICH OF THESE MIGHT MAKE YOU LEAK? cough cold weather standing up shower sexual intercourse laugh running water lifting swimming opening garage door sneeze washing dishes running walking Key in lock DO YOU WEAR PADS? NO YES If yes, how many per 24 hours? 1 2 3 4 5 6 7 8 9 When you change it, is it damp wet soaked What type do you use? Serenity Poise Tranquility Depends Kleenex Toilet paper Towels, wash cloths Baby diapers Surity Other NOCTURNAL ENURESIS: ( Wetting the bed while sleeping) YES NO If yes, how many times per month? 1 2 3 4 5 6 7 8 9 10 More Attends Major Attends Minor Generic maxipad Generic minipad
DO YOU HAVE ANY SOCIAL PROBLEMS BECAUSE OF YOUR SYMPTOMS? None Mild Moderate Severe Do you have problems with my spouse my family neither Have you stopped doing things you like to do because of your bladder? Yes No WHAT IS YOUR WORST SYMPTOM? (CHOOSE ONE ONLY PLEASE) Stress incontinence Urge incontinence Nocturnal enuresis Frequency Urgency Nocturia Pain VOIDING DIFFICULTY: (Difficulty with urinating) YES NO SOMETIMES Hesitate before urination start Leaking urine after urination Can you stop the flow, if you try? Bladder does not empty completely Having to strain to urinate Urine flow weak Urine stream starts and stops BLADDER SENSATIONS: Can you tell if your bladder is empty or full? Yes No Don t know Can you tell if your pants or pad are wet or dry without looking? Yes No Don t know Do you have burning with urination? Yes Sometimes Often Do you have pains related to your bladder? Yes Sometimes Often (In the vagina, pelvis, or pubic) If you have pain, is it relieved by urination? Yes Sometimes Often INFECTIONS AND STONES: Have you had infections in your urine (cystitis)? Yes No Don t know If yes, how many infections in the past year (approx.) Have you ever had infections in your with high fever, pain in the loins, and/or the need for hospitalization? Yes No Don t know If yes, how many years ago was the last kidney infection? Did you ever have a stone in the urinary tact? Yes No Don t know If yes, how many years since your last stone? Have you ever see blood in your urine? Yes No Don t know If yes, was it related to a bladder infection? Yes No Don t know Have you ever had an IVP? Yes No Don t know
(dye in the vein and x-ray of the kidney) If yes, how many years since the last IVP? Result BOWEL FUNCTION: How many bowel movements per week? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 More What is the common feature of your bowel habits? Constipation Diarrhea Mixture Normal Do you use laxatives? None Suppositories Oral Medication Enemas High fiber Diet Other Any difficulty controlling your bowel? None Gas Only Liquid Stools Solid Stools OBSTRETRIC AND GYNECOLOGICAL HISTORY: How old were you when you had your first period? 10 11 12 13 14 15 16 Older When was your last period? Within few weeks Within few months Post menopausal Had hysterectomy When was your last pap smear? Less than a year 2 years 3years More What was your last mammogram? Never Less than a year 2 years 3years More How many pregnancies? How many abortions? How many vaginal deliveries? How many forceps/vacuum deliveries? How many cesarean sections? Have you had a hysterectomy? If yes, how many years ago? What was the reason for the hysterectomy? Bleeding Prolapse Benign tumor Malignant tumor Contraception Other Don t know Do you think that your bladder problems are related to the hysterectomy? Yes No Don t know Are you taking any female replacement hormone therapy? None Oral pills Skin patch Other Do you have problems with recurrent vaginal infections? None Not frequent Frequent Sexual function: Do you have Dry vagina Pain during introduction Pain during intercourse Pain after intercourse CHILDHOOD HISTORY: How old were you when you stopped wetting the bed? years-old Don t know Did you have bladder symptoms, infections, or kidney infections as a child? Yes No (For example needing to urinate more than other kids or difficulty controlling your bladder at school) How many years since you started having problems with your bladder? or All my life
MEDICAL HISTORY: Do you have any of the following (circle for yes) Diabetes Heart disease Neurological disease High blood pressure Lung disease Psychiatric problems Please list any other medical problems: SURGICAL HISTORY: (List type of operation and date) MEDICATIONS: Name Dose 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. ALLERGIES: None 1. 2. 3. 4. 5.