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New Patient Form (2 of 3) 

Pregnancy History (if applicable):

Are you pregnant?
Are you nursing?

Gynecologic History (if applicable):

*Skip this section, this does not apply to me

Do you have menstrual periods?
Is your uterus still present?
Any history of abnormal PAP smear or HPV infection?
Any history of abnormal PAP smear or HPV infection?
Date of last mammogram?
Type of birth control method used?
Current or previous hormone use?

Urinary symptoms (if applicable):

*Skip this section, this does not apply to me

Do you leak urine (incontinence)?
Is it caused by coughing, laughing, sneezing, running, sports, etc?
Is the amount of urine you usually leak:
Are you bothered by a strong sense of urgency to void?
Can you overcome the sensation of urgency to void?
Can you overcome the sensation of urgency to void?
Do you sometimes not make it to the bathroom in time?
Do you lose urine without any activity or urgency?
Do you have pain or burning with urination?
Are you bothered by your incontinence?
Do you have reduced self esteem, depression, or frustration due to this issue?
Have you had evaluation for incontinence?
Are you on any prescription medication for incontinence or urgency?
Have you underwent any surgeries or procedures for incontinence?
Do you have trouble holding your flatus or stool?
Have you ever taken any GOLD containing medication?
Are you on any type of blood thinners (e.g. Aspirin, Warfairin, Fish oil, etc.)?
Topical medications?
Latex allergy?
Iodine allergy?

Social History:

Are you sexually active?
Sexual preference:
Martial status:
Do you smoke?
Do you drink alcohol?
Have you ever been abused?

Family History:

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(please check all that applies)

Thank you!

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