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Incontinence form.qxd

LONG ISLAND CENTER FOR INCONTINENCE AND VOIDING DYSFUNCTION 1. The following questionaire should only take about ten minutes to complete.
2. If you cannot answer a question, simply leave it blank.
3. DO NOT complete the gray-shaded areas.
NAME: ______________________________________________ What is your primary urinary complaint? ____________________________________________________________ How long has this been occurring? (days, months, years) ______________________________________________ ‰ sensation of still having urine in my bladder How many times do you urinate during the day?_________during the night?_________ While you are urinating, the uring flow is: When you get a strong desire to urinate, can you postpone it and not urinate? When you get a strong urge, does the urine leak out before you reach the toilet? Does urine leak out without you knowing it and you find yourself wet? If the leaking of urine is a problem, what do you use to protect your clothing? Do you use this protection during the day? How many times do you change your pads each day? Do you get repeated urinary tract infections? Have you ever noticed any blood in your urine? Urology Associates, P.C. • 535 Plandome Road • Manhasset, NY 11030 Phone: (516) 627-6188 • Fax: (516) 627-9397 LONG ISLAND CENTER FOR INCONTINENCE AND VOIDING DYSFUNCTION Have you been evaluated by a urologist or urogynocologist for voiding dysfunction? .‰ yes Have you tried any of the following medications? .‰ yes Have you been prescribed any of the following antibiotics? Have you been treated for vaginitis? .‰ yes Have you been treated for yeast infections? .‰ yes Have you been treated for any of the following sexually transmitted diseases? .‰ yes What form of contraception do you use if any? Do you have an allergy to intravenous contrast (dye)? Have you ever experienced loss of bowel control? Do you menstruate (have menstrual periods)? If yes, what is the date of your last period?_______________ How many pregnancies have you had?________ Do you experience the sensation of incomplete defecation? Do you have a sensation of pressure in the region of the vagina? Do you feel as though your uterus has “dropped”? When was your last cervical pap test?________ Have you ever had to reduce a bulge down below to urinate or Do you take hormone replacement?_________ What is the average frequency of intercourse? Do you suffer from vaginal dryness?.‰ yes Is sexual intercourse ever painful?.‰ yes Do you feel you have lost interest in sex?.‰ yes Do you feel your partner has lost interest in sex? .‰ yes Do you have diffuculty achieving orgasm?.‰ yes Does your partner have difficulty maintaining erections for satisfactory intercourse? .‰ yes Is your partner currently being treated for erectile dysfunction? .‰ yes Urology Associates, P.C. • 535 Plandome Road • Manhasset, NY 11030 Phone: (516) 627-6188 • Fax: (516) 627-9397 LONG ISLAND CENTER FOR INCONTINENCE AND VOIDING DYSFUNCTION Urology Associates, P.C. • 535 Plandome Road • Manhasset, NY 11030 Phone: (516) 627-6188 • Fax: (516) 627-9397 LONG ISLAND CENTER FOR INCONTINENCE AND VOIDING DYSFUNCTION ‰ pure stress urinary incontinence 625.6 ‰ rectocele 618.0‰ vaginal vault prolapse 618.0 ‰ enterocele 618.6‰ uterine prolapse 618.4‰ after hysterectomy 618.5 Urology Associates, P.C. • 535 Plandome Road • Manhasset, NY 11030 Phone: (516) 627-6188 • Fax: (516) 627-9397

Source: http://www.urologyassociatespc.com/incontinence.pdf

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