Urogynecology New Patient Intake Form printable pdf download

Urogynecology New Patient Intake Form

Name _____________________________________________ Date of Birth ___________________

Age _________

Referring Provider ___________________________________

What is the main reason for your visit?

_________________________________________________________________________________________________

Have you received any treatments for this issue in the past?

_________________________________________________________________________________________________

What are your goals for the visit today?

1. _______________________________________________________________________________________________

_________________________________________________________________________________________________

2. ________________________________________________________________________________________________

_________________________________________________________________________________________________

3. _______________________________________________________________________________________________

__________________________________________________________________________________________________

Urinary Symptoms:

Do you experience urinary leakage? Yes/No

If yes, how long? __________ months/years

Please check if you leak urine during the following times:

coughing/sneezing/laughing

walking/running/exercising

with intercourse

with urgency/on the way to the bathroom

minimal activity

lying down

Do you use a pad for leakage? Yes/No

If yes, how many in a day? _________

What amount of leakage do you experience?

Drops

More than drops

Flood

How long can you postpone emptying your bladder when you have the urge? _______min/hr

After emptying your bladder do you feel like you have completely finished? Yes/No

Do you find it hard to begin urinating? Yes/No

How many times do you urinate during the day? _______________

How many times do you urinate during the night after you go to sleep? ____________

Number of urinary tract infection in the last year? _____________

Any kidney infections (pyelonephritis)? Yes/No

Any history of kidney stones? Yes/No

Any blood in the urine? Yes/No

Did you have any urinary problems in childhood? Yes/No

Wake Specialty Physicians

Women's Center

Patient Label

Urogynecology New Patient Intake Form

placed here

(This form is not a part of permanent record)

10/13

PAGE 1 OF 4

WSP-214

Urogynecology New Patient Intake Form

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