Patient gynecological history

Patient Gynecological History
Appointment Date: _______________________ Name: __________________________________________ DOB: _________________ Age: ____________________ Phone #’s: Home: ________________________ Cell: ______________________ Work: _________________________ PAST GYNECOLOGICAL HISTORY (Dr. Mangal’s patients only): 1. GYN REFERRAL: Who referred you to this clinic?______________________________ 2. REASON for your office visit: _____________________________________________ If yes, please bring your partner to the consultation. 4. DELIVERIES: How many deliveries have you had? __________ How many were via C/Section? __________ 5. MISCARRIAGES: Have you had any miscarriages? No If yes, how many? __________ Did you require a D&C? __________ If yes, how many and what year(s)? _______________________________________________ 6. ECTOPIC PREGNANCY: Have you had an ectopic pregnancy? No If yes, list the year, which fallopian tube was ectopic and method of treatment (Methotrexate or surgery). ______________________________________ ______________________________________________________________________________________________ 7. MENSES: First day of last menstrual period. __________ When was the menses before the last one? __________ Age when your first menses started? (i.e.: 11, 12, 13, 14, 15, etc.) __________ How often does your menses occur (from 1st day to 1st day of next menses)? (i.e.: 21-25 days, 25-28 days, 28-35 How many days does your menstrual flow last? (i.e., 3-4 days, 5-7 days, 8-10 days, > 10 days) __________ 8. MENSTRUAL CRAMPS: Do you experience any menstrual cramps? pain level on a scale of 1-10? (“1” = no pain at all / “10” = unable to get out of bed, due to the pain) __________ As teenager, were your cramps very painful? 9. PAIN MEDS: What pain medicines have you used within the last year? (i.e.: Tylenol, Advil, Midol, Motrin, Darvocet, Vicodin, etc.) ____________________ Do pain medicines help? Powered by eIVF, a PracticeHwy.com product 10. HORMONE THERAPY: Please List chronologically (by estimated dates or by age since your teen-age years to present), any hormonal therapy you were given (i.e., birth control pills, birth control patches, Nuvaring, IUD, Depo- Provera injections, Depo-Lupron, Danazol, etc.). ______________________________________________________________________________________________ How long have stopped using contraception of any kind, prior to this visit (i.e., 6 months, 1 year, 2 years, 3 years, > 3 years)? ________________________________________________________________________________________ 11. BOWEL SYMPTOMS: When your menstrual cycle starts: do your bowel movements become looser? 12. BLADDER SYMPTOMS: Do you have to urinate more frequently when your menstrual cycle starts? Urinary frequency all the time (not just with menses)? Still feel full after emptying your bladder (urinary urgency)? Frequent urinary tract infections history? Frequent vaginal yeast infections during your lifetime? 13. DYSPARUNIA: Do you experience any pain during sexual intercourse (especially during deep penetration, like If yes, what % of the time, do you feel this pain? Does this happen every time you have sex? Do you try to avoid certain positions during sex due to pain? Do you try to avoid sex entirely because of pain? 14. PELVIC PAIN: Do you have sharp stabbing pains in the pelvis unrelated to your menses (anytime during the month), which may not last long, but can make you stop in your tracks for a moment? Intensity: Is this pain like needles or pinching? sometimes severe enough to make you “double over”? Location: Is sharp pain on right side only? Do you experience these sharp pains in upper abdomen also? ____________________ Do you experience sharp shooting pains in the Vaginal area?
experience sharp shooting pains in the rectal area? Association: Do the sharp pains in the pelvis and abdomen: 1) increase in frequency after eating food? Sometimes; 2) get better after bowel movements? In between these sharp, stabbing pains in the pelvis, do you also experience dull, aching discomfort (soreness) that seems to be present all the time (even when you don’t have the sharp pains)? Affect on quality of life: Has pain began to affect activities and quality of life: 10 at Home? Not Applicable; 4) Other? _____________________________________ Powered by eIVF, a PracticeHwy.com product 15. EMERGENCY ROOM VISITS: Have you had to go to an Emergency room for pelvic pain? these in chronological order, along with the month and the year. Include which hospital, diagnosis tests performed and their results (ultrasound, MRI, CAT scan, X-rays), and what treatment was given?): a. ____________________________________________________________________________________________ b. ____________________________________________________________________________________________ c. ____________________________________________________________________________________________ 16. GASTEROENTEROLOGIST: Were you ever referred to a Gastroenterologist in the past? these in chronological order, along with the month & year. Include each Doctor’s name; Tests performed (i.e.: colonoscopy, proctosigmoidoscopy, barium enema, upper endoscopy, upper GI series X-rays, time capsule bowel motility studies); Diagnosis given (i.e.: IBS, gastritis, gastric ulcers, esophagitis, Crohn’s disease, ulcerative colitis, spastic colon, colon polyps, internal hemorrhoids, possible endometriosis of the bowel, etc.); Treatment given (i.e.: high fiber diet, IBS meds, antacids, etc.). a. ____________________________________________________________________________________________ b. ____________________________________________________________________________________________ c. ____________________________________________________________________________________________ 17. UROLOGIST OR GYN-UROLOGIST: Have you ever been referred to an Urologist or Gyn-Urologist? If yes, list these in chronological order, along with the month & year: Include each Doctor’s name; Tests performed (i.e., cystoscopy, IVP, renal scan, MRI or CAT scan of abdomen, etc.); Diagnosis given (i.e.: Interstitial cystitis, kidney stones, pyelonephritis, hydro ureter, hydronephrosis, congenitally absent kidney, etc.); Treatment or any surgery done (i.e.: medicines to treat I.C., urethral dilation, lithotripsy, ureteral stent placement, etc.). a. ____________________________________________________________________________________________ b. ____________________________________________________________________________________________ c. ____________________________________________________________________________________________ 18. COLON RECTAL SURGEON: Were you ever referred to a Colon Rectal Surgeon in the past? If yes, list these in chronological order, along with the month & year: Include each Doctor’s name; Tests done, with results (i.e.: proctoscopy, proctosigmoidoscopy, colonoscopy, barium enema, etc.); Diagnosis given (i.e.: bowel endometriosis, any type of fistula, bowel adhesions, colon polyps, bowel obstruction, etc.); Treatment or surgery done (i.e.: small or large bowel resection and re-anastomosis, ileostomy, colostomy, appendectomy, fistula repair, etc.). a. ____________________________________________________________________________________________ b. ____________________________________________________________________________________________ c. ____________________________________________________________________________________________ Powered by eIVF, a PracticeHwy.com product 19. PULOMONOLOGIST OR THORACIC SURGEON: Were you ever referred to a Pulmonologist or Thoracic Surgeon in the past for spontaneous pneumothorax or endometriosis related chest or shoulder pains? If yes, list these visits in chronological order, along with the month & year: Each Doctor’s name; Tests and treatments a. ____________________________________________________________________________________________ b. ____________________________________________________________________________________________ c. ____________________________________________________________________________________________ 20. CHRONIC PAIN MANAGEMENT SPECIALIST: Were you ever referred to a chronic Pain Management Specialist in No If yes, list in chronological order, along with the month & year: Each Doctor’s name; Tests and treatments done (which pain meds, nerve stimulator implant, steroid injections, nerve block, etc.) a. ____________________________________________________________________________________________ b. ____________________________________________________________________________________________ c. ____________________________________________________________________________________________ 21. STRESS COUNSELING: Were you ever referred to a Stress counselor/Psychologist/ or Psychiatrist in the past? No If yes, list these in chronological order, along with the month& year: Each therapists name; Diagnosis (i.e., stress, anxiety, depression, etc.); Treatment given (i.e., exercise, acupuncture, anti-anxiety meds, antidepressant a. ____________________________________________________________________________________________ b. ____________________________________________________________________________________________ c. ____________________________________________________________________________________________ 22. PRIMARY CARE PHYSICIAN: Do you have a PCP who follows your pelvic and/or abdominal pain? If yes, please list the name and phone number. ________________________________________________________ 23. GENERAL GYNECOLOGISTS: Have you seen more than one “general” gynecologist in the last 5 years? No If yes, list these in chronological order with the month & year: Each Doctor’s name; Diagnostic Tests done with results (i.e.: pelvic ultrasound, Hysterosalpingogram, etc.); Diagnosis given (i.e.: mild, moderate or severe endometriosis, ectopic pregnancy, PID, fibroids, polyps, intrauterine adhesions, pelvic adhesions, congenital uterine abnormality, etc.); Treatment or surgery done with findings (D & C, hysteroscopy, laparoscopy, laparotomy-open abdominal incision, myomectomy, c-section, tubal ligation, hysterectomy via laparoscopic, robotic, vaginal or a. ____________________________________________________________________________________________ b. ____________________________________________________________________________________________ c. ____________________________________________________________________________________________ Powered by eIVF, a PracticeHwy.com product 24. STD’s: Have you had any sexual y transmitted infections? What year? __________
What year? __________
What year? __________
What year? __________
25. PMS: Do you experience premenstrual symptoms? Yes / other __________________________________________ 26. PAP SMEAR: When was your last pap smear? __________
Have you ever had an abnormal pap smear? No If yes, then did you have treatment? __________ If
yes, what was the treatment (i.e.: cryo, LEEP, cone biopsy) and date? _____________________________________ ______________________________________________________________________________________________ 27. MAMMOGRAM: If > 35 years old, have you had a mammogram? No If yes, when? __________
Result? _______________________________________________________________________________________ 28. OLD SURGERY RECORDS: If you have had any abdominal surgeries in above Question Number 23, please have copies of those records (Operative reports and any pathology reports from those surgeries), faxed from your doctor to Dr. Mangal’s office ASAP. This will assist Dr. Mangal in determining the type of appointment you will need. It may take up to one week to review your records. Thank you for your assistance in getting these records in an expedited PLEASE FAX THIS FORM BACK TO Dr. MANGAL @ (713) 512-7679!
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Source: http://www.fertilityhouston.net/pdf/mangal-gynecological-questionnaire.pdf