History Form For Patients With Interstitial Cystitis printable pdf download

History Form For Patients With Interstitial Cystitis

If you have urinary frequency or pain, please fill this out prior to your visit.

When was your bladder last “normal”?

Date:_____________________

How frequently do you go to the bathroom during the day? Every ___________ minutes.

How many times do you get up at night to urinate? _____________________

On the average, how many times do you urinate in twenty-four hours? ______________

Please list all medications that you are currently taking along with their dosages. We need to know

every medication whether it is an alternative medicine, an herbal medicine, an over the counter

medicine, or a prescription medicine.

_________________________________________________________________________________

____________________________________

Do you have any bowel problems? Do you have diarrhea? ___Do you have constipation?

_____ Have you seen a GI doctor in the last year? ______ Have you had a Colonoscopy in the last

two years? ______

Do you have any gynecologic problems? ________ Does your pain occur at a particular time during

your menstrual cycle? __________ When was your last monthly period? ______ Could you be

pregnant? ________ When was your last visit to the gynecologist? _______When was your last

pelvic ultrasound? ____________

Do you have pelvic pain? ________ If so, where? _____________________________

Please try to calibrate the degree of your pelvic pain. #1=minor #10=very bad. Your pain today is

what # on the scale? _______ Your pain is usually what # on the scale? ______ How many days per

month do you have the pain? ________

Does your bladder hurt when it is full? __________

Has any prior treatment ever helped you? _________________________________

Has any prior treatment ever made your condition worse? ________________________

Have you ever had a potassium sensitivity test? ________Have you ever had a bladder biopsy?

__________

Have you ever been diagnosed with Depression ________ Fibromyalgia ___________

Headaches ________ Irritable Bowel Syndrome ___________ Gluten sensitivity ____

History Form For Patients With Interstitial Cystitis