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New Patient Form (3 of 3) 

New Patient Physical Examination

Skin type

Gynecology Examination:

Itroitus:
Estrogenization:
Clitorl Reflex:
Anal Wink:
Perineal Body:
Vulvar/Perineal/Vaginal:
Vaginal Pelvic Floor Muscle Tone:
Squeeze Test:
Vaginal Circumference (# digits)
Cystocele Stage: (lateral/central/combined):
Rectocel (distal/proximl) Stage:
Enterocele Stage:
Vaginal cuff prolapse Stage:
Tendeness on palpation:
Uterus:
Size:
Prolapse Stage:
Right Adnexa:
Left Adnexa:
Rectal Tone:
Hemorrhoids
Vagina Laxity
Labia Minora Asymmetry
Discussions:

Thank you!

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