WOMEN's CONTINENCE CENTER of GREATER ROCHESTER Hilary Cholhan, M

Kimberly Miller-Miles, M.D.

450 Medical Center Blvd., Suite 410

Webster, Texas 77598

713-578-3860 (Main) ● 281-338-2982 (Fax)

PelvicRestorativeCenter.com

Date: ______

Dear: ______

Welcome to the Women’s Pelvic Restorative Center–Bay Area. This letter is to confirm your appointment with Dr. Kimberly Miller-Miles at the Women’s Pelvic Restorative Center-Bay Area office. Our office is located at 251 Medical Center Blvd. ~ Suite 230 (2nd Floor), Webster, Texas77598.

*Please plan toarrive30 minutes prior to your appointment.

If you take an antibiotic before you go to the dentist or if you have an artificial heart valve, a catheter or a pacemaker please contact your regular doctor for his/her advice on the necessity of taking an antibiotic before we see you.

Please take a few minutes to review the enclosed papers. PLEASE BRING THE COMPLETED PATIENT PACKET TO YOUR FIRST SCHEDULED APPOINTMENT - YOU MAY KEEP THE FIRST PAGE FOR YOUR RECORDS. Several appointments have been made for you and are listed on the back of this sheet. Not all patients need all appointments, but it is easier to cancel one than to add one in a pinch. Please note that we may have to reschedule your appointment if your paperwork is not completed at the time of your first visit. Enclosed you will find:

1.Medical history - 2 pages front and back

2.24 hour voiding diary - directions on one side, blank to complete on the other side

3.Voiding questionnaire - One page front and back

In addition, please bring the following:

A copy of your most recent mammogram report (not the actual x-ray film)
If you have had previous pelvic surgery, please have a copy of the OPERATIVE REPORT sent to us from your surgeon or the hospital where it was performed. There is more than one surgical procedure that can be done to correct urinary incontinence or a bulge. Not knowing the exact name of the surgery that you had can potentially limit our ability to assist you.
Please bring your insurance card. All co-payments are due at the time of each visit.

In order to devote full attention to you, we do not "double book" patients or appointments. Therefore, as a courtesy to our staff and to other patients, we kindly ask that you give us 24 hours notice if you must cancel or reschedule your appointment

Additionally, appointments are for a specific time frame. Please respect the time of other patients. If you have reached the conclusion of your appointment time and need additional time to discuss your health condition, we will be pleased to arrange for a follow-up appointment.

Thank you for your attention to these matters. Please feel free to call should you have any questions prior to your visit. We look forward to meeting you.

Sincerely,

Kimberly Miller-Miles, MD and the Staff of the Women’s Pelvic Restorative Center-Bay Area

APPOINTMENTS

Part I (30-45 minutes): ______

Part II (30 minutes): ______

Part III (60 minutes): ______

Consult (45 minutes): ______

We would like to thank you for the opportunity to serve you.
WPRC Health Care Providers: / Peter M. Lotze, M.D.
Ginger N. Cathey, M.D.
KimberlyR.Miller-Miles, M.D.
HilaireW.Fisher, M.D.

URINARY INCONTINENCE IN WOMEN

Urinary incontinence is a common condition. An estimated 15-30% of women experience incontinence. Although it should never be considered normal, it is significantly more common in elderly women and even more common in nursing home patients. (Men also experience urinary incontinence, but much less frequently than women and it usually occurs following radical surgery or with other neurologic disorders).

TYPES OF URINARY INCONTINENCE

The two most common types of incontinence are stress urinary incontinence and urge incontinence. Both of these types of incontinence can be effectively treated using a combination of behavior modification techniques and pelvic floor muscle exercises. Other therapy options include surgical correction for stress urinary incontinence and pharmacologic therapy for Detrusor Instability (“overactive bladder”).

Stress urinary incontinence in the majority of cases is due to a loss of support to the urethra, which is the structure that carries the urine from the bladder to the outside of the body. When there is a loss of support to the urethra, urine loss can occur during activities that increase abdominal pressure (i.e. cough, sneeze, aerobic exercise, lifting, etc.). Causes of this loss of urethral support include: childbirth, which may change the structure supports of the urethra and may be the cause of pelvic floor nerve damage; chronic cough; constipation; and other conditions which tend to create chronically increased pressures within the abdomen.

Urge incontinence is the loss of urine associated with an involuntary and uncontrollable urge to urinate. Urge incontinence occurs when the bladder muscle becomes overactive and no longer responds to normal reflex, and/or central (brain) commands telling the bladder to relax. This bladder hyperactivity is called Detrusor Instability if there is no evidence of any underlying neurologic disorder. The cause of this condition is unknown. Many neurological conditions such as a stroke, Parkinson's disease, and Multiple Sclerosis can lead to similar complaints of urge incontinence.

TREATMENT OPTIONS

Numerous treatment options are available for our patient’s complaint(s). Appropriate options are identified through patient assessment. Options available to patients for their complaint(s) based on their findings may include (but are not limited to) the following services offered through our clinic:

Women’s Pelvic Restorative Center

Revised: 04/2018

Pessaries for urinary incontinence
Pessaries for pelvic support problems
Kegel exercise instruction
Biofeedback
Lifestyle modification for urinary incontinence
Bladder retraining drills / voiding schedules
Medication management for incontinence
Therapy for inflammatory states of the bladder
Surgery for pelvic support problems
Surgery for stress incontinence

Women’s Pelvic Restorative Center

Revised: 04/2018

Coordination with other support services for multiple medical complaints (including colorectal surgery, certified nutritionist assessment, and physical therapy)

KimberlyMiller-Miles, M.D.
450 Medical Center Blvd., Suite 410
Webster, Texas77598
713-578-3860 (Main) ●281-338-2982 (Fax)

Who referred you to our office?

Myself

A friend/family member ______

Doctor / Health Care Provider: ______

(Please include his / her phone number)

Please list the name(s) of your physician(s) and their office address(es).

Physician Name / Specialty / Office Address / Office Phone / Fax

MEDICAL HISTORY QUESTIONNAIRE

DIRECTIONS: Please read and complete. Thank you.

Women’s Pelvic Restorative Center

Revised: 04/2018

Women’s Pelvic Restorative Center

Revised: 04/2018

Name: ______

Age: ______

Date Completed: ______

Birth Date: ______

Women’s Pelvic Restorative Center

Revised: 04/2018

Please write down why you are coming for this evaluation and what results you would like to have.

______

Please fill in the following information in the blanks provided.

Obstetric

Number of: Pregnancies: _____ Number of vaginal deliveries: _____

Number of caesarean sections: _____ Miscarriages:_____ Abortions:_____

Current birth control method: ______

Gynecology

Age when periods started ______Date of last period ______Are your periods regular? Yes / No

Number of days from start of one period to next How long does your period last?

Have you gone through menopause? Yes / No

If Y (yes), at age ______Reason for menopause: Natural ____ Hysterectomy _____

Have you had any bleeding since menopause? No ____ Yes ____

Women’s Pelvic Restorative Center

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Do you have any of the following?

 Bleeding between periods For how long? ______

 Bleeding after intercourse For how long? ______

 Heavy menstrual periods For how long? ______

Date of last Pap smear? Results?

Where was Pap smear done? ______

DES exposure? No _____ Yes _____

(DES is a drug your mother would have taken to prevent her from having a miscarriage. You would have been exposed to DES while she was pregnant with you.)

Have you had any treatment to your cervix? Y / N (if Yes, please indicate below)

 Cautery Date ______Reason ______

Cryosurgery Date ______Reason ______

 Other ______Date ______Reason ______

Gynecology (continued)

Please circle if you had any of the following: (if Yes, please give date)

Infection in your female organs? Y / N Date ______

Venereal Disease?Y / N Date ______

Herpes? Y / N Date ______

Please answer.

Are you sexually active? Y / N

Is your sex life satisfactory to you? Y / N

Date of last mammogram? ______Result ______

Where was your mammogram done? ______

Past Medical History

As an adult have you had any of the following: (if yes, please check)

Women’s Pelvic Restorative Center

Revised: 04/2018

Heart Disease

Liver Disease

Asthma / COPD

Kidney Disease

Tuberculosis

Jaundice

Kidney Infection

High Blood Pressure

Thyroid disease

Diabetes

Neurological disease

Stroke

Women’s Pelvic Restorative Center

Revised: 04/2018

Mitral Valve Prolapse

Other ______

Women’s Pelvic Restorative Center

Revised: 04/2018

Past Surgical History

Have you had any operations Y/ N (If yes, please list below)

Surgery Month/Year (or your age at the time of surgery)Complications (if any)

______

Have you ever had a blood transfusion? Yes / No

If Yes, did you have a reaction? Yes / No

Medicines

Do you do any of the following?

Smoke Y / N If yes, how many packs per day? ______How long? ______

Use Alcohol? Y / N

Use street drugs? Y / N

Have drug allergies? Y / N If yes, please list ______

Please list all medications (AND DOSES) you are currently taking, including vitamins and contraceptives.

______

Family History

Please check if anyone in your family has/had these diseases and list relationship.

High blood pressure Relationship______

Stroke Relationship ______

Heart disease Relationship ______

Diabetes Relationship ______

Breast cancer Relationship ______

Other cancer Relationship ______

Other Relationship ______

Social History Please answer.

Current marital status: ______

Number of people living in your household: ______

Your occupation: ______

Spouse’s occupation: ______

Health Habits Please answer.

How many hours do you sleep at night? ______

Do you eat regular meals, including breakfast? ______

Do you eat whole grain bread and cereal,

fresh fruits and vegetables daily? ______

Do you exercise regularly? ______

If yes, what type of exercise? ______

How often? ______

What do you do to relax? ______

Do you consider yourself healthy? ______

Women’s Pelvic Restorative Center

Revised: 04/2018

Review of Systems Please indicate if you have had any of the following RECENTLY. Circle Yes or No. If Yes, please explain. Please circle “Yes” OR “No” for each response. We will not be able to see you until every question has been circled Yes or No. NO EXCEPTIONS.

Constitutional Symptoms . Integumentary

Fever Y / N Skin Rash Y / N

Chills Y / N Boils Y / N

Headache Y / N Persistent Itch Y / N

Other ______Other ______

Eyes Musculoskeletal

Blurred Vision Y / N Joint Pain.Y / N

Double Vision Y / N Neck Pain Y / N

Pain Y / N Back Pain Y / N

Other ______Other ______

Allergic/Immunologic Ear/Nose/Throat/Mouth

Hay Fever Y / N Ear Infection Y / N

Drug Allergies Y / N Sore Throat Y / N

Greatly

Urine leakage related to the feeling of urgency
(sudden desire to urinate)?

/ 0 / 1 / 2 / 3

Urine leakage related to physical activity,
coughing, or sneezing?

/ 0 / 1 / 2 / 3

Small amounts of urine leakage (drops)?

/ 0 / 1 / 2 / 3

Difficulty emptying your bladder?

/ 0 / 1 / 2 / 3

Pain or discomfort in the lower abdominal or genital area?

/ 0 / 1 / 2 / 3

Urogenital Distress Inventory-Short form

UDI-6 Scoring. Item responses are assigned values of 0 for "not at all," 1 for "slightly," 2 for "moderately," and 3 for "greatly." The average score of items responded to is calculated. The average, which ranges from 0 to 3, is multiplied by 33 1/3 to put scores on a scale of 0 to 100.

Quality of life due to urinary problems

If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that? Please draw an “X” across the scale below to best reflect your feelings about your urinary problem.

Pleased Terrible

|______|______|______|______|______|______|

Some people find that accidental urine loss may affect their activities, relationships, and feelings. The questions below refer to areas in your life that may have been influenced or changed by your problem. For each question, circle the response that best describes how much your activities, relationships, and feelings are being affected by urine leakage.

Has urine leakage affected your… / Not at All / Slightly / Moderately /

Greatly

1. Ability to do household chores
(cooking, house cleaning, laundry)? / 0 / 1 / 2 / 3
2. Physical recreation such as walking, swimming, or other exercise? / 0 / 1 / 2 / 3
3. Entertainment activities (movies, concerts, etc.)? / 0 / 1 / 2 / 3
4. Ability to travel by car or bus more than 30
minutes from home? / 0 / 1 / 2 / 3
5. Participation in social activities outside your home? / 0 / 1 / 2 / 3
6. Emotional health (nervousness, depression, etc.)? / 0 / 1 / 2 / 3
7. Feeling frustrated? / 0 / 1 / 2 / 3

Incontinence Impact Questionnaire– Short Form IIQ-7

NAME: ______DATE: ______

These questions ask about symptoms you may have related to urine leakage. Please circle the number that represents how frequently you experience each symptom.

0
Never / 1
Rarely / 2 Sometimes / 3
Often
Does coughing gently cause you to lose urine?
Does coughing hard cause you to lose urine?
Does sneezing cause you to lose urine?
Does lifting things cause you to lose urine?
Does bending cause you to lose urine?
Does laughing cause you to lose urine?
Does walking briskly or jogging cause you to lose urine?
Does straining, if you are constipated, cause you to lose urine?
Does getting up from a sitting to a standing position cause you to lose urine?
Some women receive very little warning and suddenly find that they are losing, or are about to lose, urine beyond their control. How often does this happen to you?
If you can’t find a toilet or find that the toilet is occupied, and you have an urge to urinate, how often do you end up losing urine or wetting yourself?
Do you lose urine when you suddenly have the feeling that your bladder is very full?
Does washing your hands cause you to lose urine?
Does cold weather cause you to lose urine?
Does drinking cold beverages cause you to lose urine?

MESA Questionnaire

NAME:DATE:

Gas / Stool Leakage (Incontinence)

Please answer all of the questions in the following survey:

These questions will ask you if you have certain bowel symptoms and if you do how much they bother you.

Answer these questions by circling the appropriate box or boxes. If you are unsure about how to answer a question, give the best answer you can.

WOMEN's CONTINENCE CENTER of GREATER ROCHESTER Hilary Cholhan, M

APPOINTMENTS

Part II (30 minutes): ______

URINARY INCONTINENCE IN WOMEN

TYPES OF URINARY INCONTINENCE

Name: ______

Number of days from start of one period to next ______How long does your period last? ______

Date of last Pap smear? ______Results? ______

Where was Pap smear done? ______

Venereal Disease?Y / N Date ______

Herpes? Y / N Date ______

Are you sexually active? Y / N

______

Have you ever had a blood transfusion? Yes / No

If Yes, did you have a reaction? Yes / No

Greatly

Urogenital Distress Inventory-Short form

UDI-6 Scoring. Item responses are assigned values of 0 for "not at all," 1 for "slightly," 2 for "moderately," and 3 for "greatly." The average score of items responded to is calculated. The average, which ranges from 0 to 3, is multiplied by 33 1/3 to put scores on a scale of 0 to 100.

Greatly

Number of days from start of one period to next How long does your period last?

Date of last Pap smear? Results?