Gynecology Urogynecology Minimally Invasive Surgery

LAWRENCE LIN M.D., FACOG

Gynecology --- Urogynecology --- Minimally invasive surgery

Simi Valley Thousand Oaks

We welcome you and thank you for selecting us for your healthcare needs. We are dedicated to providing you with the best personalized healthcare and solutions. If you have any questions or need help, please ask us.

MEDICAL HISTORY QUESTIONNAIRE

Name ______Birth Date ______

Age _____ # Pregnancies ______# Births______[Vaginal___ Cesarean_ ] Miscarriages/Abortions______

Referring Physician______

Primary Care Physican______

How did you hear about us? ______

HISTORY OF PRSENT ILLNESS or CHIEF COMPLAINT: (Why do you want to see the doctor today?)

______

PAST MEDICAL HISTORY: ______

______

PAST SURGICAL HISTORY OR HOSPITALIZATIONS:

TYPE OF SURGERY DATES (YR) REASON

______

SOCIAL HISTORY: Marital Status: Single [ ] Married [ ] Widowed[ ] Divorced [ ]

Tobacco use: Yes [ ] No [ ] Daily Amount ______Number of years______

Alcohol use: Yes [ ] No [ ] Daily Amount ______Number of years ______

Substance abuse: Yes [ ] No [ ] Type of substance abuse______

Coffee/Tea use: Yes [ ] No [ ] Number of cups per day ______

MEDICATIONS (ALSO INCLUDE VITAMINS AND HERBAL MEDICATION)

NAME OF MEDICATION DOSAGE TIMES PER DAY REASON

______

ALLERGIES:

[ ] No known drug allergies

[ ] Allergies to medication (What type of meds and what type of reaction?) ______

GYNECOLOGIC SYMPTOMS SEXUAL HISTORY

1) Your age at first period: ______

2) Do you have menstrual periods? ……………………………………………[ ] Yes [ ] No

a) If you have periods, are they: [ ] Regular [ ] Irregular. If irregular periods, for how long? ______

b) If you have periods, are they: [ ] Scant [ ] Normal [ ]Heavy [ ] Painful.

c) If painful periods, the pain occur [ ] Before [ ] During [ ] After menses? And for how long (mo/yrs)____

3) When was your last Pap smear (years)? ______Have you had any abnormal Pap smears [ ] Yes [ ] No

a) If abnormal pap smears, have you had treatment for abnormal Pap smears? ______

4) Is sexual activity an important consideration? [ ] Yes [ ] No

5) Are you sexually active now? [ ]Yes [ ] No. If not sexually active,[ ] Personal choice

is the reason due to:[ ] Decreased sex drive

[ ] Vaginal problems (lubrication, pain)

[ ] Partner problem (impotence, no partner)

[ ] Other ______

a)If you are sexually active, is your sex life satisfactory to you [ ] Yes [ ] No

b)If you are sexually active, do you have pain with intercourse? [ ] Yes [ ] No

b) If you are sexually active, do you have bleeding with intercourse?[ ] Yes[ ] No

6) Current birth control method? [ ] None

[ ] Tubal ligation

[ ] Pills

[ ] Depo Provera shot

[ ] Condoms

[ ] Others ______

7) Have you ever had any infections in your female organs? [ ] Yes [ ] No. If yes, what type? ______

(e.g. Gonorrhea, Syphilis, Chlamydia, Herpes, Genital warts, HIV, Hepatitis)

8) Do you have problems with constipation? [ ] Yes [ ] No If yes, explain ______

9) Do you have problems with: [ ] Losing gas

[ ] Loss of loose stool

[ ] Loss of solid stool

[ ] None

BLADDER SYMPTOM QUESTIONNAIRE

[ ] I do NOT have any bladder problems (Please continue to the next page)

[ ] I do have bladder problems (If so, continue with the questions below)

1) How often do you urinate?…….during the day? ______

……..during the night?______

2) Do you leak urine (incontinence)?...... [ ] Yes [ ] No

a)If you leak urine, duration of leak (months or years)? ……………………………...______

b)If you leak urine, is it caused by coughing, laughing, running, lifting things?…….[ ] Yes [ ] No

c)Do you lose urine during intercourse………………………………………………[ ] Yes [ ] No

3) Do you have urgency and frequency of urination? ………………………………………..[ ] Yes [ ] No

a) Are you bothered by a strong sense of urgency to void? ……………….…………[ ] Yes [ ] No

b)Do you lose urine without warning? ………………………………………………..[ ] Yes [ ] No

c) If urgency and frequency, how often to you need to go to the bathroom?……….[ ] Every 15 minutes

[ ] Every 30 minutes

[ ] Every 1 hour

[ ] Every 2 hours

[ ] Every 3 hours or longer

d) Do you sometimes leak before you can make it to the bathroom (urgency)?...... [ ] Yes [ ] No

e) What activities seem to cause you to leak urine? …………………[ ] Sight / Sound of running water

[ ] Standing up after being seated

[ ] “Key in the door” when you return home

[ ] Other______

4) Do you need to wear a pad for your protection for leakage of urine………………………[ ] Yes [ ] No

a) How many pads do you need to change daily? ……………………(circle one): 2 4 6 8 10 12+

5) Do you have difficulty starting your urinary flow?………………………………………[ ] Yes [ ] No

a) Is your urine flow ……………………………………………(circle one): Strong Weak Dribbling Intermittent

6) Has urine leakage or prolapse affected your: (Please circle the correct response for each)

Not at all Slightly Moderately Greatly

(a) Ability to do household chores (cooking, house-cleaning, laundry) ? 0123

(b) Physical recreation such as walking, swimming, or other exercise?0123

(d) Ability to travel by car or bus more than 30 minutes from home?0123

(e) Participation in social activities outside your home?0123

(f) Emotional health (nervousness, depression, etc)0123

(g) Feeling frustrated?0123

REVIEW OF SYSTEMS (PLEASE CIRCLE YOUR ANSWERS)

If yes, please circle ALL the symptoms that apply to you.

1) CONSTITUTIONALNONEHEALTH PROBLEM,WT LOSS, WEIGHT GAIN, FEVER, CHILLS, FATIGUE,

LOSS OF APPETITE, HEADACHE

2) EYESNONEVISION CHANGE, GLAUCOMA, EYE DISEASE, EYE INFECTION,

GLASSES/CONTACT, BLUR VISION, DOUBLE VISION, CATARACT

3) NOSE, THROAT, MOUTHNONE SINUSITIS, EAR RINGING, HEARING LOSS, EAR INFECTION, BAD BREATH, NOSE

BLEED, GUM BLEED, DIFFICULT SWALLOWING

4) CARDIOVASCULARNONE SHORTNESS OF BREATH WITH WALKING OR LYING FLAT, CHEST PAIN. EDEMA,

HEART TROUBLE, PALPITATION, MITRAL VALVE PROLAPSE

5) RESPIRATORYNONEWHEEZING, ASTHMA, SPITTING UP BLOOD, SHORTNESS OF BREATH,

CHRONIC COUGH,

6) GASTROINTESTINAL NONEULCER, BLOODY STOOL, CONSTIPATION, FLATULENCE, NAUSEA/VOMITING,

DIARRHEA, ABDOMINAL PAIN, JAUNDICEE

7) GENITAL TRACTNONEPAINFUL SEX, DISCHARGE, ITCHING, BURNING, STDs, DECREASED LIBIDO

VAGINAL DRYNESS, SEXUAL DYSFUNCTION, ABNORMAL BLEEDING,

8) URINARY TRACTNONEFREQUENCY, BLOOD IN URINE, BURNING, PAINFUL, LEAKING URINE WHEN

COUGHING OR SNEEZING, INCOMPLETE EMPTYING, KIDNEY STONE, URGENCY

9) MUSULOSKELETAL NONEJOINT PAIN, STIFFNESS, SWELLING, MUSCLE WEAKNESS, DIFFICULTY WALKING,

COLD EXTREMITIES, GOUT, FRACTURE, INJURY,BACK PAIN,

10) BREASTNONEBREAST PAIN, DISCHARGE, MASSES, SKIN RASH, ULCERS, ITCHING, CHANGE IN

NAILS, HAIR OR COLOR, PSORIASIS, ECZEMA, HIVES

11) NEUROLOGICALNONESYNCOPE, SEIZURES, NUMBNESS, TINGLING SENSATIONS, TROUBLE WALKING,

TREMORS, PARALYSIS, DIZZINESS, FAINTING SPELLS, STROKE

12) PSYCHIATRIC NONEDEPRESSION, CRYING, MEMORY LOSS, NERVOUSNESS, INSOMNIA, CONFUSION,

IRRITABILITY, MENTAL ILLNESS, MOODINESS, PHOBIAS

13) ENDOCRINENONEHOT FLASHES, NIGHT SWEAT, DIABETES, THYROID DISEASE, DRYER SKIN,

HEAT/COLD INTOLERANCE, HAIR LOSS, EXCESSIVE THIRST/URINATION

14) HEMATOLOGICNONEENLARGED GLANDS, SLOW TO HEAL CUT, PAST BLOOD

TRANSFUSION,BLEEDING OR BRUISING TENDENCY, ANEMIA, PHLEBITIS

15) ALLERGIC/IMMUNONONE (BESIDES MEDICINE LISTED ABOVE)

FAMILY HISTORY (ANY CHRONIC ILLNESS WHICH HAS OCCURRED IN ANY BLOOD RELATIVE)

[ ] None

[ ] Cancer ______[ ] High blood pressure ______

[ ] Bleeding disorder ______[ ] Breast Cancer ______

[ ] Heart Disease ______[ ] Stroke ______

[ ] Diabetes ______[ ] Others ______