INITIAL HISTORY AND PHYSICAL - FEMALE
(This section to be completed by patient.)
DUKE UNIVERSITY
DIVISION OF UROLOGY
Patient Name___________________________________ Medical Record # ___________________
Date_______________________________ Age________ Phone__________________________________
Referring Physician: _____________________________________________________________________
CHIEF COMPLAINT (Why you want to see the doctor today?):_____________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
BLADDER SYMPTOM QUESTIONNAIRE (circle symptoms that are present now)
How often do you urinate: During the day? ____________________ At night? ________________________________
Is the amount of urine you usually pass :
Large
Average
Small
Do you lose urine (incontinence) ? ..................................................................................................... Yes
No
Duration of incontinence?
_____________ Months ____________ Years
Is it caused by activities such as coughing, laughing, running, playing sport, etc.? ............... Yes
No
Do you need to wear protective ‘pads’ for this type of incontinence? ................................................ Yes
No
Do you lose your urine during intercourse? ........................................................................................ Yes
No
if yes - With deep penetration? ................................................................................ Yes
No
- With orgasm? ............................................................................................... Yes
No
List other activities that trigger leakage:________________________________________________________________
_______________________________________________________________________________________________
Do you have to rush to the bathroom? …………………………………………………………………….Yes
No
Have you leaked urine while rushing to the bathroom?..................................................................... Yes
No
Do you have a strong urge to void or leakage with the following activities:
- Putting the keys in the door….. ....................................................................... Yes
No
- Going from sitting to standing ......................................................................... Yes
No
Do you lose urine without any warning (without activity or feeling urgency to urinate)? ..................... Yes
No
When urinating, can you usually stop your stream? ........................................................................... Yes
No
Do you ever wet the bed while asleep? .............................................................................................. Yes
No
Would you describe the amount of urine that you leak as being (you may answer more than one)
- Frequent small volumes…… ........................................................................... Yes
No
- Unconscious/continuous loss (always damp or wet) ...................................... Yes
No
- Infrequent but single large volumes of loss …………. ..................................... Yes
No
How many pads do you usually use per day for protection? (circle choice)
1, 2, 3, 4, 5, 6, 7, 8, more.
List any medications you have tried for incontinence___________________________________________________
List any prior surgeries for incontinence or prolapse (include dates)______________________________________
______________________________________________________________________________
Do you have to you have a slow stream?.........................................................................................Yes
Do you have to strain to urinate?......................................................................................................Yes
Do you have to change positions to urinate?....................................................................................Yes
Do you have to push on the bladder to void?....................................................................................Yes
No
No
No
No
Do you have frequent urinary infections……………………………………………………………………Yes
How often have these occurred in recent years? 1, 2, 3, 4 or more per year (circle your choice)
Do you ever see blood in your urine?................................................................................................Yes
Do you have pain during urination?...................................................................................................Yes
Do you have pain in the lower abdomen?.........................................................................................Yes
Is the pain related to:
Your bladder being full?
Yes
No
Your menstrual cycle?
Yes
No
Intercourse?
Yes
No
Bowel movements?
Yes
No
No
No
No
No
PROLAPSE SYMPTOM QUESTIONNAIRE (circle symptoms that are present now)
Do you have a feeling of vaginal fullness or pressure?......................................................................Yes
Can you see or feel a swelling protruding from the vagina?...............................................................Yes
Do you push the protrusion back to help have a bowel movement or to empty your bladder?..........Yes
Are you sexually active?.....................................................................................................................Yes
If not sexually active: Is the reason due to:
No
No
No
No
Decreased sex drive?...............................................................................................Yes
No
Vaginal dryness/pain?...............................................................................................Yes
No
Partner problems (impotence, widowed, divorced)?.................................................Yes
No
Is sexual activity an important consideration in how we manage your problem?......Yes
No
Do you have problems with: losing gas, loss of loose stool or solid stool? (circle your choice); # episodes per week ____
Do you have serious problems with constipation? Yes No
If yes, how long _______ months _______ years
Number of bowel movements per week? _______________
How often do you take a laxative per week? _________
Do you need to use pressure against your vagina to have a bowel movement? ................................................... Yes No
GYNECOLOGIC SYMPTOM QUESTIONNAIRE
# of pregnancies? __________ # of vaginal deliveries?______________ # of cesarean sections?____________________
Was your last menstrual period within the last one month, 6 months, one year, or longer? (circle your choice)
If you are taking hormones, please list them:_____________________________________________________________
If you have periods, are they: regular / irregular, heavy / moderate / scant, painful?
(circle your choice)
If you have painful periods, does the pain occur before or during the menses?
(circle your choice)
When was your last PAP smear? _________________) Was it normal / intermediate / abnormal? (circle one)
Are you having any abnormal vaginal discharge or discomfort? ....................................................................... Yes No
MEDICAL PROBLEMS (List problems like high blood pressure, diabetes, heart attacks, strokes, cancer,
etc.)___________________________________________________________________________________
_______________________________________________________________________________________
PAST SURGERIES OR HOSPITALIZATIONS
Please list with date:_________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
FAMILY HISTORY (check illness which has occurred in any blood relative and write relationship to you):
____ Cancer______________________________
____ Bleeding Disorder __________________________
____ Heart disease_________________________
____ Others ___________________________________
____ Diabetes_____________________________
______________________________________________
SOCIAL HISTORY
Marital status:
S
M
W
D
Occupation___________________________________________
Tobacco use:
Yes
No
Daily amount ______________
Number of years_____________
Alcohol use:
Yes
No
Daily amount ______________
Number of pregnancies__________ Number of vaginal births________ Weight of largest baby__________
MEDICATION HISTORY
Please list all current medications and dosages if known:____________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Allergies to medication: (list)
No known allergies______________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
________________________________________________________________________________________
REVIEW OF SYSTEMS (other current health problems):
Are you physically active? Describe_____________________________________________________________________
Do you now have or have you ever had:
Cardiac (heart) problems? ............................Yes No
Cancer (specify)______________ ............... Yes No
Gastrointestinal (stomach) problems? ..........Yes No
Thyroid problems? ......................................... Yes No
Depression? ..................................................Yes No
Psychiatric problems? ................................... Yes No
Liver problems? .............................................Yes No
Kidney problems (stones, nephritis)? ............ Yes No
Diabetes (insulin dependent/oral medication) _________________________________ .......................... Yes No
Neurologic (seizures, headaches, weakness, paralysis) problems? ........................................................... Yes No
Musculoskeletal (bones, joints, muscles) problems?
....................................................................... Yes No
Hematologic (bleeding, anemia) bleeding problems?
....................................................................... Yes No
Circulation problems (varicose veins, thrombosis)?
....................................................................... Yes No
__________________________________________________________________________________________
__________________________________________________________________________________________
(THIS SECTION TO BE COMPLETED BY PHYSICIAN)
PHYSICIAN SUMMARY OF PRESENTING COMPLAINT: _________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
PHYSICAL EXAMINATION
Vitals: BP__________ Temp___________ Pulse ___________ Ht___________ Wt__________BMI___________

General appearance:

Head and face: NCAT

Eyes:
+/- glasses, ocular movements equal and intact, conjunctivae clear

ENMT:
No external lesions of the ears, nose, oral mucosa clear, +/-dentures

Neck/Thyroid:
Masses, asymmetric, enlargement

Respiratory:
Respiratory effort, breath and adventitious sounds

Cardiovascular: RRR, murmurs/rubs/gallops, peripheral vascular system (swelling, varicosities, pulse, temp, edema)

Gastrointestinal: Prior surgical incisions, masses, tenderness, hernia, visceromegaly

Genitourinary:
o
External genitalia- appearance, hair distribution, lesions)
o
Urethral meatus- cough stress test, hypermobility, size, location, lesions, prolapse
o
Urethra- masses, tenderness, scarring, diverticulum
o
Bladder- fullness, palpable, masses, tenderness
o
Vagina
General appearance- parous, stenotic, s/p radiation

Estrogen affect- atrophic, pink with rugous, dryness

Discharge, lesions, mesh erosion, pain
o
Cervix- present/absent, lesions, length, discharge
o
Uterus- present, absent, support, size, contour, position, CMT
o
Adnexa/parametria- eg tenderness, masses
o
Prolapse- central/lateral cystocele, uterine prolapse, enterocele, rectocele, perineocele
o
Anus and perineum (eg sphincter tone, perineocele, perineal splaying, rectal prolapse, hemorrhoids)
o
Pelvic floor strength (1-9)
o
Perineal sensation and reflexes (eg. S2,3,4 sensation, anal wink)
o
POP-Q measurements:
o
o
o
o
o
Aa
Ba
C
Lower ant wall
Upper ant wall
Cervix/Cuff
-3 to +3
-3 to +TVL
-TVL to +TVL
GH
PB
TVL
Genital hiatus
Perineal body
Total vaginal length
Ap
Bp
D
Lower post wall
Upper post wall
Posterior fornix
-3 to +3
-3 to +TVL
-TVL to +TVL
Lymphatic- neck, axillae, groin
Extremities- edema
Musculoskeletal- range of motion, gait
Skin- rashes, lesions, ulcers
Neurological/psychiatric- orientation, mood, affect
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LABORATORY DATA:
Urinalysis:
RBC’s _______WBC’s_______Other Abn.________Cr ________Other___________________________
BLADDER DIARY:
Functional Capacity:________ Average Voiding Volume __________ Total 24 Hr Volume ________
# of incontinent episodes per 24 hrs: _______________ (# urge ________; # stress _______)
24 HOUR PAD WEIGHT: __________________________________________________________
RADIOGRAPHIC STUDIES:
Ultrasound: ______________________________________________________________________________________
CT scan: ________________________________________________________________________________________
RUG: ___________________________________________________________________________________________
Other: __________________________________________________________________________________________
PROCEDURES: (straight catheterization, bladder instillation, pessary fitting, uroflowmetry, bladder scan, PTNS,
Interstim programming, excision of mesh, etc.)
_________________________________________________________________________________________________
_______________________________________________________________________________
CYSTOSCOPY:
Masses, lesions, foreign bodies, mesh extrusion:__________________ Efflux:_________________________________
Urethral fistula, diverticulum, mesh extrusion, coaptaion:____________________________________________________
URODYNAMICS:
CMG:
Capacity:________________________ Stable / Unstable: ____________________
Sensation: ______________________ aLPP: _____________________________
Voiding Study:
det/Qmax _______________________ Contraction: sustained / unsustained
Residual: ________________________
Fluoroscopy:____________________________________________________________________________
Other data:_____________________________________________________________________________
INITIAL IMPRESSION:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
DISPOSITION:
_______________________________________
STUDIES SCHEDULED:
___________________________________________
___________________________________________
___________________________________________
___________________________________________
Labs: 
UDS: 
RUS: 
IVP: 
Others:
_______________________________________
_______________________________________
CONSULTATIONS SCHEDULED:
___________________________________
___________________________________
_____________________________________
_____________________________________
________________________
________________________
________________________
________________________
______________________
COMPLETED DICTATION:
Clinic Note
 ___________________
Referring Physician  ___________________
SIGNED: ______________________________
Rev 9/17/12
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