New Patient forms (No Bladder Diary)

Welcome to Princeton Urogynecology!

Please complete the forms as completely as possible. Submitting the forms at least 24 hours before of you appointment, will help give your provider the time they need to best prepare for your appointment.
When is your upcoming appointment? IMPORTANT: If you do not have a scheduled appointment date yet, please DO NOT complete the forms. They will not be able to be linked to a chart or stored in the system. Wait until you have a scheduled date.

Month Day Year
Date

Patient's Medical and Surgical History
Medical History
Reason for Visit *
Other (please fill in below)
Obstetric History
Number of pregnancies: *
Vaginal Deliveries:
Cesarean Deliveries:
Largest Baby Weight:
Forceps or Vacuum?

Yes No
Episiotomy?

Yes No
3rd or 4th Degree Laceration or Tear?

Yes No
Other Delivery Details
Other Complications or Prolonged Labor
Gynecologic History
Gynecologist Name:
Gynecologist Phone Number:
Date of Last PAP Smear:
Last PAP Smear Results:
Date of Last Mammogram:
Last Mammogram Results:
Are you sexually active at the present time?

Yes No
Have you had any sexually transmitted diseases? If yes, when?
Are you using contraception? If yes, what type?
Are you presently taking, or have you taken in the past, hormone replacement therapy? If yes, medication and dose schedule, vaginal/oral:

Do you experience any of the following? *

Yes

Bleeding between periods

Heavy menstrual periods

Pain with periods

Bleeding after intercourse

Pain with intercourse

"Falling" of pelvic organs/prolapse

Medical Conditions and Medications
Surgical History:
Have you had any surgeries or hospitalizations?
SURGICAL & HOSPITAL HISTORY: (include ALL operations with month/year, serious injuries, and hospitalizations)
Medical Conditions:
Do you have any medical conditions?
MEDICAL CONDITION(S): (ex: high blood pressure, asthma, history of stroke, etc.)
Medications:
Do you take and medications or supplements?
MEDICATION(S): name, dose, frequency and reason (ex: HCTZ, 25mg daily, high blood pressure)
Allergies:
Do you have any medication allergies?
Drug Allergies: *
Reactions:
Social History:

Yes/No

Quantity

How often

Drug Use:

Alcohol Use:

Smoking:

Highest Level of Education:
Employment (Job Title):
Family History:
Review of Systems:

Yes

(Specify)

Weight Change

Fatigue

Recent Fever

Recent Vision Changes

History of Glaucoma

Heart Palpitations

Easy Bruising

Prolonged Bleeding

Recent Cough

Shortness of Breath

Nausea/Vomitting

Diarrhea

Bloody Stool

Abdominal Pain

Constipation

Flank Pain

Pain with Voiding/ Passing Urine

Blood in the Urine

Abnormal or Heavy Vaginal Discharge

Abnormal of Heavy Vaginal Bleeding

Recent Muscle Weakness

Recent Rash

Syncope (Fainting)

History of Neuropathy

Depression

Anxiety

Hot Flashes

Adenopathy (Swollen Glands)

Dry Mouth

OTHER

Pelvic Health Questionnaires

(Urinary Distress Inventory) In the last 3 months have you experienced & been bothered by: *

Not At All

Somewhat

Moderately

Quite Often

Frequent Urination?

Urine leakage with sense of urgency (strong need to go to the bathroom)?

Leakage with coughing, sneezing, or laughing

Small amounts of urine leakage (drops)?

Difficulty emptying bladder?

Pain/discomfort in lower abdomen or genital region?

(Colorectal-Anal Distress Inventory) In the last 3 months have you experienced & been bothered by: *

Not At All

Somewhat

Moderately

Quite Often

Straining too hard to have a bowel movement?

Feeling of incomplete emptying of bowel movement?

Losing stool beyond your control if your stool is well-formed?

Losing stool beyond your control if your stool is loose?

Losing gas from the rectum beyond your control?

Having pain with passing stool?

Strong sense of urgency/rushing to the bathroom to have a bowel movement?

Part of your bowel ever pass through the rectum and bulge outside during or after a bowel movement?

(POP Distress Inventory) In the last 3 months have you experienced & been bothered by: *

Not At All

Somewhat

Moderately

Quite Often

Pressure in the lower abdomen?

Heaviness or dullness in the pelvic area?

A bulge or something falling out that you can see or feel in your vaginal area?

Need to push on the vagina or around the rectum to have/complete a bowel movement?

Sensation of incomplete bladder emptying?

Need to push up the bulge into the vaginal area with your fingers to urinate?

(Pelvic Floor Impact Questionnaire) How do the following symptoms/conditions usually affect your: *

BLADDER or URINE

BOWEL or RECTUM

VAGINA or PELVIS

Ability to do household chores? (cooking, cleaning, laundry, etc.)

Ability to do physical activities? (Walking, swimming, exercise, etc.)

Entertainment activities, such as going to a movie or concert?

Ability to travel by car or bus for a distance greater than 30 minutes away from home?

Participation in social activities outside your home?

Emotional health? (Nervousness, depression, etc.)

Feeling frustrated?

PISQ- Prolapse/Incontinence Sexual Function Questionnaire

Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (Your responses should be based on your sexuality over the past 6 months

Response

Are you currently sexually active?

** If your answer is No, you do not need to complete the rest of this form

Response

How frequently do you feel sexual desire? (This feeling may include wanting to have sex, planning to have sex, feeling frustrated due to lack of sex, etc.)

Response/Frequency

Do you climax (have an orgasm) when having sexual intercourse with your partner?

Do you feel sexually excited (turned on) when having sexual activity with your partner?

How satisfied are you with the variety of sexual activities in your current sex life?

Are you incontinent of urine (leak urine) with sexual activity?

Does fear of incontinence (stool or urine) restrict your sexual activity?

Do you avoid sexual intercourse because of bulging in the vagina? (I.e.the bladder, rectum, or vagina falling out)

When you have sex with your partner, do you have negative emotional reactions such as fear, disgust, shame, or guilt?

Does your partner have a problem with erections that affects your sexual activity?

Does your partner have a problem with premature ejaculation that affects your sexual activity?

Do you feel pain during sexual intercourse?

Response

Compared to orgasms you have had in the past, how intense are the orgasms you have had in the past six months?

Submit Forms and Upload Any Additional Files
Additional Documents
You may add any documents (ex: ultrasound, lab data, etc) to share with your provider here.

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Welcome to Princeton Urogynecology!

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Medical History

Obstetric History

Gynecologic History

Medical Conditions and Medications

Surgical History:

Medical Conditions:

Medications:

Allergies:

Social History:

Family History:

Review of Systems:

PISQ- Prolapse/Incontinence Sexual Function Questionnaire

Additional Documents

Thank you completing our forms!