Female Pelvic Medicine and Reconstructive Surgery
401 East Chestnut Street, Suite 460
Louisville, KY 40202
Telephone (502) 588-4402  Fax (502) 588-4403
Welcome to our practice of Female Pelvic Medicine and Reconstructive Surgery. We are
located in the U of L Out-Patient Care Building on the corner of Preston Street and East Chestnut
Street in downtown Louisville.
To best serve you in a timely effective manner, we need some detailed medical history about
you. The enclosed history form will help us start your treatment as quickly as possible. It is
long and very detailed. You may find that you need a family member, friend, or information
from your doctor to help you complete your history. We advise you to begin completing the
form as soon as you receive it.
If your insurance requires a referral from your primary care physician, please obtain this prior to
your visit. Also note that all co-pays are due at the time of service.
Please bring your completed forms to your scheduled appointment. Unfortunately, if we do not
have a completed form and questionnaire, we will need to reschedule your appointment. Also,
bring all pertinent information, such as medical records, your current list of medications and your
insurance cards.
For your visit, please arrive at least 15 minutes prior to your scheduled appointment. Be aware
during your visit, you will be seen by a team of healthcare professionals which includes the
physician, fellows and residents of the University of Louisville in participation of your care.
If you have any questions prior to your visit, please call (502) 588-4402.
Sincerely,
University of Louisville Physicians
OB/GYN & Women’s Health
Doctor: ________________________________
Appointment Date:
Time:
If you are unable to keep this appointment, please notify our office 24 hours in advance.
Revised 2/28/13 be
CONSENT FOR MEDICAL CARE
I wish to have treatment given to:  me  my child  my ward by University of Louisville
Physicians OB/GYN & Women’s Health. I voluntarily consent to routine diagnostic and
therapeutic procedures such as physical exams, vaccinations, and lab tests. As part of the care to
be given, a test may be performed for human immunodeficiency virus infection (HIV/AIDS),
hepatitis, or other blood-borne infectious or communicable diseases. If the doctor orders the test
for diagnostic purposes, because of my/the patient’s medical history, symptoms, or conditions.
I hereby acknowledge that I have read and fully understand the information set forth above and
that any questions have been answered to my satisfaction.
______________________________________
Patient
________________________________
Date
I hereby state that I am the  parent  legal representative of the patient and am authorized to
sign on their behalf.
______________________________________
Parent/Legal Representative
________________________________
Date
I have reviewed the above information with the patient, parent, or legal representative as
appropriate.
______________________________________
Parent/Legal Representative
________________________________
Date
Revised 2/28/13 be
URINARY INCONTINENCE
YES
NO
Y
N
How many months or years have you had leakage of urine?
Y
N
Do you wear pads to absorb lost urine?
If yes, what size pad do you wear?
How many pads do you wear in a day?
How many trips to the bathroom do you make during the day from the time you
wake up in the morning until the time you go to sleep at night?
Y
N
How many times are you awakened during the night after going to sleep to
urinate?
Does an uncomfortably strong need to pass urine wake you up?
Y
N
I lose urine with changes in posture, standing or walking
Y
N
Do you lose urine during orgasm?
Y
N
Do you notice any dribbling or urine when you stand after passing your urine?
Y
N
Have you ever required catheterization for the inability to pass your urine?
Y
N
Y
N
Do you ever feel that your bladder is not emptying completely after passing
urine?
Have you seen any blood in your urine?
Y
N
Do you have any burning with urination?
Y
N
Have you had 3 or more urinary tract infections in the last year?
Y
N
Have you seen a physician for complaints of urine loss?
Y
N
Have you had surgery to prevent urine loss?
Y
N
If yes, was it done through the vagina?
Y
N
Was it done through the abdomen?
Y
N
Have you taken medicine to prevent urine loss?
If yes, name the medication ______________________________________
Revised 2/28/13 be
GENITOURINARY PROLAPSE
How many months or years have you had this bulge or mass?
Y
N
Have you seen a doctor for this bulge or mass in your vagina?
Y
N
Have you worn a pessary for this problem?
If yes, how many months or years have you worn this pessary?
Y
N
Have you had surgery in the past for a bulge or mass in the vagina?
FECAL INCONTINENCE
__yr __mo How many months or years have you had accidental loss of stool or gas?
Y
N
Have you seen a doctor for this problem?
Y
N
Did the problem with accidental loss of stool begin after childbirth?
Y
N
Did you wear protective pads for this problem?
If yes, what size pad do you wear?
How many pads do you wear each day?
Y
N
Are you able to sense the need to have a bowel movement?
Y
N
Are you able to tell the difference between solid stool/liquid stool/gas?
Y
N
Do you have a frequent desire to have a bowel movement?
Y
N
Do you feel that your bowels are never completely empty?
Y
N
Have you had surgery for this problem?
Y
N
Has there been a change in your bowel habits recently?
Y
N
Have you noticed any bright red bleeding with your bowel movements?
Y
N
Have you noticed black or “tarry” stools?
Y
N
Are your bowel movements painful?
Revised 2/28/13 be
CONSTIPATION
Do you have constipation?
Y
N
Do you excessively strain to pass stool more than 25% of the time?
Y
N
Do you have less than three bowel movements each week?
Y
N
Do you pass hard, small stool?
Y
N
__yr __mo How many months or years have you had constipation?
Have you seen a doctor for this problem?
Y
N
Do you use any medication or over the counter products for constipation?
Y
N
If yes, what have you used? ______________________________________
Y
Y
N
N
Have you had surgery for this problem?
Y
N
Do you have a feeling of incomplete emptying after bowel movements?
Y
Y
N
N
Have you had any surgery for urinary leakage?
Have you ever placed your hand or fingers in your vagina or between your
vagina and rectum to help bring about a bowel movement?
Have you had surgery for prolapse, or bulges?
Revised 2/28/13 be
401 E. Chestnut Street, Suite 460
Louisville, KY 40202
(502) 588-4402
PATIENT PAYMENT POLICY
Thank you for choosing our medical practice. We are committed to provide the best possible medical care. The following
information is provided to avoid any confusion regarding payment for professional medical services. Please sign below that you have
read and agree to this policy.
Contracted Insurance Policy. If an insurance company with whom we have a contractual agreement insures you, you will be
responsible for your co-payment and/or any deductible or non-covered service at the time the service is rendered.
Non-Contracted Insurance Policy. If any insurance company with whom we do not have a contractual agreement insures you, you
will be responsible for payment in full at the time service is rendered. This includes a $25 service fee for completion of Disability
and FMLA forms.
Minors of Divorced Parent. The parent(s)/guardian accompanying the patient is/are responsible for payment at the time service is
rendered.
Payment Policy
 Payment for service is due in full at the time of service.
 We accept cash, check, Visa, MasterCard, and Discover
 All fees are based on the type of service provided for your care and related services
 If the patient is a minor (18 years and younger), the parent or guardian is responsible for payment of the account in
accordance with the policies outlined above
 For elective or uncovered surgical services, all co-payments and deductibles are due prior to your surgery
 If your account is more than 60 days overdue, it will be referred to an outside collection agency. Collection and court costs
will be added to the patient’s account should this become necessary
 In the event that you cancel any services that were scheduled and a deposit was issued via credit card, you will be charged a
one-half (1/2) % administrative fee of the refunded amount which will be automatically deducted
Referrals
It is your responsibility to bring any required referrals for treatment at, or prior to, the time of your visit. If you do not have a referral,
your visit could be rescheduled, or you may financially be responsible. Other providers (anesthesiologists, radiologists, pathologists,
and hospitals who may provide care to you during the time you are under the care of one of the University of Louisville Physicians
OB/GYN & Women’s Health, it is the PATIENT’S responsibility to ensure that these other providers are participating providers with
your insurance carrier.
Acknowledgement and Authorization: I have read, understand, and agree to the above Payment Policy. I understand that charges
not covered by insurance company as well as copayments and deductibles my responsibility to pay at the time services are rendered. I
authorize my insurance benefits to be paid directly to University of Louisville OB/GYN & Women’s Health. I authorize University of
Louisville OB/GYN & Women’s Health to release any medical or other information to my insurance company when requested.
___________________________________________
Patient/Parent/Guardian Signature
________________________________
Date
It is the patient’s responsibility to inform us of any insurance changes. If we do not have your current insurance information,
payment is expected at time of service.
Revised 2/28/13 be
COMMUNICATION WITH FAMILY AND OTHERS INVOLVED IN YOUR CARE
This form allows you, as the patient, to choose those persons you want to include and allow access to your
medical information. This communication can be changed or voided by you at any time; however, we cannot
retrieve information that has already been shared.
Name: _____________________________________
Date of Birth: _________________
SSN: ______________________________________
Medical Record#: ______________
Please list any family members or other show may be involved in coordinating your care. Also, please
indicate what kinds of information may be share with each person listed.
TYPE OF INFORMATION
Name:
Relationship to Patient:
All
____________________
__________________
_____
____________________
__________________
____________________
Appointment
Medical
Billing
_____
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__________________
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We will continue to rely on the information on this form when communicating with family members or
others involved in your care unless you request changes. Please promptly notify your physician’s office if
you wish to alter the designations above.
Patient Signature or Legal Representative: _______________________________________________________
Relationship to Patient: ______________________________________________________________________
Revised 2/28/13 be
Revised 2/28/13 be
Referred By:
___
Address: ___________________________________
Phone #:___________________________________
Patient Name:
Address:
City:
Phone #:
Cell #:
Spouse/Parent:
Address:
City:
Phone #:
Cell #:
Email:
__
State:
Zip:
Work #:
Email:
_
_
State:
Work #:
Zip:
Name of nearest relative not living with you:
Relationship:
Address:
City:
State:
Zip:
Soc. Sec. #: ________ / ___________ _/
Birth Date:
_
/
_/
Employer:
_______
Occupation:
_____
Soc. Sec. #:
Birth Date:
Occupation:
Employer:
Address:
_____ /
______ /
/
/
____
____
______
Phone #:
Work #:
__
Cell #:
____
__
_
__
AUTHORIZATION TO RELEASE INFORMATION: I HEREBY AUTHORIZE University of Louisville Physicians OB/GYN &
Women’s Health to release any medical or incidental information that may be necessary for either medical care or in
processing applications for financial benefit.
ASSIGNMENT OF INSURANCE BENEFITS: I HEREBY AUTHORIZE direct payment of surgical/medical benefits to
University of Louisville Physicians OB/GYN & Women’s Health for services rendered by them in person or under their
supervision. I understand that I am financially responsible for any balance not covered by my insurance.
PATIENT NAME (Print):
Date:
___
PATIENT (GUARDIAN) SIGNATURE:
**A photocopy of these assignments shall be valid as the original.
Date:
___
HEALTH HISTORY
Name: _____________________________________________ DOB: _________________________________
Today’s Date: _______________________________________ Date of Last Physical Exam: _______________
SYMPTOMS: Check
symptoms you are currently having or have had in the past year.
GENERAL
 Chills
 Dizziness
 Fainting
 Fever
 Weight Loss
 Numbness
 Sweating
EYES, EARS, NOSE, THROAT
 Bleeding Gums
 Blurred Vision
 Crossed Eyes
 Difficulty Swallowing
 Double Vision
 Earache
 Ear Discharge
 Hay Fever
 Hoarseness
 Hearing Loss
 Nosebleeds
 Persistent Cough
 Ringing in Ears
 Sinus Problems
CARDIOVASCULAR







Chest Pain
High Blood Pressure
Irregular Heart Beat
Low Blood Pressure
Poor Circulation
Rapid Heart Beat
Swollen Ankles
RESPIRATORY
 Cough
 Shortness of Breath
 Decrease in Exercise
GI









Abdominal Pain
Poor Appetite
Bloating
Bowel Changes
Constipation or Diarrhea
Gas
Heartburn or Indigestion
Hemorrhoids
Nausea or Vomiting
GENITOURINARY
 Blood in Urine
 Frequent Urination
 Lack of Bladder Control
 Painful Urination
MUSCLES/JOINTS/BONES
Pain, weakness or numbness in:
 Arms
 Back
 Feet
 Hands
 Hips
 Legs
 Neck
 Shoulders
SKIN
 Bruise Easily
 Hives
 Itching
 Change in Moles
 Rash
 Scars
 Sores Not Healing
NEURO
 Dizziness/Lightheadedness
 Weakness
 Fainting
 Seizures
PSYCHIATRIC
 Depression
 Headache
 Loss of sleep
 Nervousness
 Stress
 Trouble Concentrating
ENDOCRINE
 Diabetes
 Hypertension
 Thyroid Disease
HEMATOLOGIC
 Anemia
 Bleeding Disorder
ALLERGIES
 Asthma
 Hay Fever or Allergic Rhinitis
WOMEN ONLY
 Abnormal Pap Smear
 Bleeding Between Periods
 Breast Lump
 Extreme Menstrual Pain
 Hot Flashes
 Nipple Discharge
 Painful Intercourse
 Vaginal Discharge
Date of Last Menstrual Period
_______________________
Date of Last Pap smear
_______________________
Date of Last Mammogram
_______________________
Are You Pregnant? Y/N
Number of Children ______
CONDITIONS - Check















conditions you are currently having or have had in the past year.
AIDS
Alcoholism
Anemia
Anorexia
Appendicitis
Arthritis
Asthma
Bronchitis
Bulimia
Cancer
Cataracts
Chemical Dependency
Chicken Pox
Emphysema
Epilepsy















Glaucoma
Goiter
Gonorrhea
Gout
Heart Disease
Hepatitis
Hernia
Herpes
HIV Positive
Kidney Disease
Liver Disease
Measles
Migraines
Miscarriage
Mononucleosis
 Mumps
 Pacemaker
 Pneumonia
 Polio
 Prostate Problem
 Psychiatric Care
 Rheumatic Fever
 Scarlet Fever
 Stroke
 Tonsillitis
 Other:
___________________
___________________
___________________
PAST SURGICAL HISTORY: List surgeries you have had in the past and the year it was performed.
1.
3.
2.
4.
MEDICATIONS/ALLERGIES: List medications you are currently taking AND Allergies to medications.
MEDICATIONS
ALLERGIES
1.
5.
1.
2.
6.
2.
3.
7.
3.
4.
8.
4.
FAMILY HISTORY:
FAMILY MEMBER
AGE
HISTORY OF ANY ILLNESS
AGE AT
DEATH
CAUSE OF DEATH
FATHER
MOTHER
BROTHERS
SISTERS
PREGNANCY HISTORY:
YEAR OF BIRTH
SEX OF CHILD
DELIVERY TYPE
COMPLICATIONS IF
ANY
SOCIAL HISTORY: Check any substance that you are currently using and how often.
Caffeine
Tobacco
Alcohol
Other
I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of
his/her staff responsible for any errors or omissions that I may have made in the completion of this form.
_____________________________________________________
Patient Signature
_____________________________________________________
Physician Signature
__________________________
Date
__________________________
Date
AUTHORIZATION FORM FOR THE USE AND/OR DISCLOSURE OF PROTECTED HEALTH INFORMATION
401 East Chestnut St.
Suites, 410, 470
Louisville, KY 40202
(502) 588-4400
(502) 588-4401 (Fax)
550 So. Jackson St.
Louisville, KY 40202
(502) 561-8850
(502) 561-8851 (Fax)
401 E. Chestnut Street
Suite 460
Louisville, KY 40202
(502) 588-4402
(502) 588-4403 (Fax)
550 So. Jackson St.
Ultrasound Department
Louisville, KY 40202
(502) 561-8838
(502) 561-8839 (Fax)
529 So. Jackson St., 3rd Fl,
Louisville, KY 40202
(502) 561-7220
(502) 561-7327 (Fax)
This authorization, if signed, will authorize University of Louisville Physicians OB/GYN & Women’s Health to use and/or disclose
certain protected health information that is in the practice’s possession about the person named below:
PATIENT NAME: ___________________________________ DATE OF BIRTH: ______________________________
I here by authorize the use and/or disclosure of my protected health information as described below:
Dates of Service
_____All
_____________
_____Progress Note
_____________
_____Test Results
_____________
_____Consultation reports
_____________
_____Operative Report
_____________
_____Photos, videotapes, or other images
_____________
_____Other (please list)
_____________
_____Ultrasound
_____________
____________________________________________________________________________________________________________
1.
My authorization applies to the information described above. Only this information may be used and/or disclosed pursuant
to this authorization:
2.
I understand that this information may include information related to Acquired Immunideficiency Syndrome (AIDS) or
Human Immunodeficiency Virus (HIV) infection, treatment for drug or alcohol abuse, or mental, behavioral health, or
psychiatric care.
1.
(a) Person or facility requesting records:
Name: Dr. Azadi/Francis
Address: 401 East Chestnut Street, Suite 460
City, State, Zip: Louisville, KY
Phone: (502) 588-4402 Fax: (502)588-4403
(b) Person or facility releasing records:
Name: ______________________________________________________________________________________
Address: ____________________________________________________________________________________
City, State, Zip: _______________________________________________________________________________
Phone: _______________________________________________ Fax: __________________________________
2.
The protected health information being used and/or disclosed under this authorization is for the following purpose (you may
leave this blank if you are the patient or the patient’s legal guardian and the protected health information is being released to
you): __________________________________________________________________________
3.
I understand that if my protected health information is disclosed to someone who is not required to comply with federal
privacy regulations, then such information may be re-disclosed and would no longer be protected.
4.
I understand that I have the right to revoke this authorization in writing, at any time, by sending such written notification to
University of Louisville Physicians OB/GYN & Women’s Health (please specifiy practice site). I also understand that my
request is not effective for actions already completed.
5.
Unless otherwise revoked, I understand that this authorization will expire one hundred and eighty days (180) from the date of
this form or on the following date or event:
I understand that I do not have to sign this authorization as a condition of being treated by UofL OB/GYN & Women’s Health. I
certify that I have received a copy of this authorization.
____________________________________________________
Signature (Patient or Patient’s Representative)
________________________________________
Date
_________________________________________________________________________________________________
Printed name of Patient’s respresentative given authority to act for patient
_________________________________________________________________________________________________
Relationship to Patient
Center for Female Continence PFDI-20
PT INITIALS
I.D. Number
Pre
, 3 mo
DOB
, 6mo
, 12 mo
, 24 mo
, 36 mo
DATE
Research Site
, 60 mo
POPDI-6
1. Usually experience pressure in the lower abdomen?
No
Yes If yes, how much does it bother you?
Not at all Somewhat Moderately Quite a bit
Score
2. Usually experience heaviness or dullness in the pelvic area?
No
Yes If yes, how much does it bother you?
Not at all Somewhat Moderately Quite a bit
Score
2. Usually have a bulge or something falling out that you can see or feel in
your vaginal area?
No
Yes If yes, how much does it bother you?
Not at all Somewhat Moderately Quite a bit
Score
3. Ever have to push on the vagina or around the rectum to have or
complete a bowel movement?
No
Yes If yes, how much does it bother you?
Not at all Somewhat Moderately Quite a bit
Score
4. Usually experience a feeling of incomplete bladder emptying?
No
Yes If yes, how much does it bother you?
Not at all Somewhat Moderately Quite a bit
Score
6. Ever have to push up on a bulge in the vaginal area with your fingers to
start or complete urination?
No
Yes If yes, how much does it bother you?
Not at all Somewhat Moderately Quite a bit
PFDI-20
P.I.
DOB
Date
CRADI-8
7. Feel you need to strain too hard to have a bowel movement?
No
Yes If yes, how much does it bother you?
Not at all Somewhat Moderately Quite a bit
Score
8. Feel you have not completely emptied your bowels at the end of a bowel
movement?
No
Yes If yes, how much does it bother you?
Not at all Somewhat Moderately Quite a bit
Score
9. Usually lose stool beyond your control if your stool is well formed?
No
Yes If yes, how much does it bother you?
Not at all Somewhat Moderately Quite a bit
Score
10. Usually lose stool beyond your control if your stool is loose?
No
Yes If yes, how much does it bother you?
Not at all Somewhat Moderately Quite a bit
Score
11. Usually lose gas from the rectum beyond your control?
No
Yes If yes, how much does it bother you?
Not at all Somewhat Moderately Quite a bit
Score
12. Usually have pain when you pass your stool?
No
Yes If yes, how much does it bother you?
Not at all Somewhat Moderately Quite a bit
Score
13. Experience a strong sense of urgency and have to rush to the bathroom
to have a bowel movement?
No
Yes If yes, how much does it bother you?
Not at all Somewhat Moderately Quite a bit
Score
14. Does par of your bowel ever bulge outside the rectum during or after
a bowel movement? No
Yes If yes, how much does it bother you?
Not at all Somewhat Moderately Quite a bit
Score
CRADI-8 Total
x 25=
UDI-6
15. Usually experience frequent urination?
No
Yes If yes, how much does it bother you?
Not at all Somewhat Moderately Quite a bit
Score
16. Usually experience urine leakage associated with a feeling of urgency, i.e.
i.e. a strong sensation of needing to go to the bathroom?
No
Yes If yes, how much does it bother you?
Not at all Somewhat Moderately Quite a bit
Score
17. Usually experience urine leakage with coughing, laughing, or sneezing?
No
Yes If yes, how much does it bother you?
Not at all Somewhat Moderately Quite a bit
Score
18. Usually experience small amounts of urine leakage (small drops of urine)?
No
Yes If yes, how much does it bother you?
Not at all Somewhat Moderately Quite a bit
Score
19. Usually experience difficulty emptying your bladder?
No
Yes If yes, how much does it bother you?
Not at all Somewhat Moderately Quite a bit
Score
20. Usually experience pain or discomfort in the lower abdomen or genital
region?
No
Yes If yes, how much does it bother you?
Not at all Somewhat Moderately Quite a bit
Score
UDI-6 Total
x 25 =
Scale scores: Obtain the mean value of all of the answered items within the corresponding
scale (possible value 0 – 4) and then multiply by 25 to obtain the scale score (range 0 – 100).
Missing items are dealt with by using the mean from answered items only.
PFDI-20 Summary Score: Add the scores from the 3 scales together to
obtain the summary score (range 0 – 100).
POPDI-6
CRADI-8
UDI-6
PFDI-20 SCORE