Belleville_Symptom

Date of Initial Appointment

Who referred you to BIHC?

Reason(s) for Visit

Client Information

Name

Age

DOB

Date

Occupation

Pronouns

She/Her/HersHe/Him/HisThey/Them/TheirsOther

Anatomy

I have a vulvaI have a penisI have had gender affirming surgery

Bladder Symptoms

Do you ever leak urine?

YESNO

Do you leak urine with activities such as coughing, sneezing, laughing, physical activity?

YESNO

Do you have strong urge sensations to urinate?

YESNO

Do you leak urine after having an intense urge to urinate that feels uncontrollable?

YESNO

Causes of your urgency?

Key in the doorCold Running waterOther

Urination Frequency:

EVERY ____ HRS

____ x PER DAY

____ x PER NIGHT

Do you feel you fully empty your bladder?

YESNO

Do you strain to urinate?

YESNO

Do you have pain with urination?

YESNO

Do you wear pads for incontinence?

YESNO

If yes, # per day? ______

Have you had any recent urinary tract infections?

YESNO

Fluid Intake in 24 hours:

# OF CUPS OF COFFEE

# OF CUPS OF WATER

# OF CUPS OF TEA

# OF CUPS OF OTHER FLUIDS

On a scale of 1-10, how much do your bladder symptoms interfere with your quality of life?

Bowel History

Frequency _____ x per week

____ x per day

Do you have fecal incontinence?

YESNO

Do you have fecal urgency?

YESNO

Do you feel you have constipation?

YESNO

Do you feel that your bowels fully empty?

YESNO

Stool Consistency:

LooseSoft/formedHardVaries

Answer if applicable

# of Pregnancies

# of live births

Weight of heaviest baby: lbs

Weight of heaviest baby: oz

Length pushing stage

Complications

C-section births

YESNO

# of C-section births

Forceps?

YESNO

Episiotomies?

YESNO

Tears?

YESNO

GRADE

Age of Children

Last Pap

Normal?

YESNO

Vaginal infections

Sexually Transmitted Infections

Menstrual Cycle

YESNONONE

Regular?

YESNO

Menopause

YESNO

Age of onset

Perimenopause/Menopause Symptoms

Hormone Replacement?

YESNO

Do you feel heaviness or pressure in your vaginal area?

YESNO

Have you ever been diagnosed with a prolapse?

YESNO

Are you sexually active?

YESNO

Have you ever had your prostate checked?

YESNON/A

Have you ever been treated for a prostate condition?

YESNON/A

What was it?

Last PSA score:

When was it taken?

Can you achieve erection?

YESNON/A

If yes, are they painful?

YESNO

Pain History

Do you have pelvic pain?

YESNO

Where do you feel your pain?

How long have you had pain?

How would you describe your pain?

What makes your pain better?

Worse?

Do you have pain with sexual activity?

YESNO

If yes, please describe:

How strong would you rate your pain on average?

How intense was your worst pain during the past 4 weeks?

Medical History

Abdominal Surgery

Pelvic Surgery

Medical Tests Completed

Medical Treatments

Do you exercise?

YESNO

Level of activity:

If yes, what do you do?

Do your symptoms prevent you from exercising?

YESNO

Goals For Treatment:

Central Sensitization Inventory: Part A

(N) NEVER (R) RARELY (S) SOMETIMES (O) OFTEN (A) ALWAYS

Please select the best response to the right of each statement:

	N	R	S	O	A
I feel unrefreshed when I wake up in the morning.
My muscles feel stiff and achy.
I have anxiety attacks.
I grind or clench my teeth.
I have problems with diarrhea and/or constipation.
I need help in performing my daily activities.
I am sensitive to bright lights.
I get tired very easily when I am physically active.
I feel pain all over my body.
I have headaches.
I feel discomfort in my bladder and/or burning when I urinate.
I do not sleep well.
I have difficulty concentrating.
I have skin problems such as dryness, itchiness or rashes.
Stress makes my physical symptoms get worse.
I feel sad or depressed.
I have low energy.
I have muscle tension in my neck and shoulders.
I have pain in my jaw.
Certain smells, such as perfumes, make me feel dizzy and nauseated.
I have to urinate frequently.
My legs feel uncomfortable and restless when I am trying to go to sleep at night.
I have difficulty remembering things.
I suffered trauma as a child.
I have pain in my pelvic area.

Central Sensitization Inventory: Part B

Have you been diagnosed with any of the following disorders by a doctor?

	NO	YES
Restless leg syndrome
Chronic fatigue syndrome
Fibromyalgia
Temporomandibular joint disorder (TMJ)
Irritable bowel syndrome
Multiple chemical sensitivities
Neck injury (including whiplash)
Anxiety or panic attacks
Depression

Restless leg syndrome - Diagnosis

Chronic fatigue syndrome - Diagnosis

Fibromyalgia - Diagnosis

Temporomandibular joint disorder (TMJ) - Diagnosis

Irritable bowel syndrome - Diagnosis

Multiple chemical sensitivities - Diagnosis

Neck injury (including whiplash) - Diagnosis

Anxiety or panic attacks - Diagnosis

Depression - Diagnosis

DASS Questionnaire

Please read each statement and circle a number, 0, 1, 2, or 3, which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

S =

A =

D =

0 = It did not apply to me at all
1 = Applied to me to some degree or some of the time
2 = Applied to me a considerable degree, or a good part of the time
3 = Applied to me very much, or most of the time

DASS Questionnaire

	0	1	2	3
I find it hard to wind down (S)
I was aware of the dryness of my mouth (A)
I could not seem to experience any feeling at all (D)
I experiences breathing difficulty (eg. excessively rapid breathing, breathlessness in the absence of physical exertion (A)
I found it difficult to work up the initiative to do things (D)
I tended to overreact to situations (S)
I experienced trembling (eg. hands) (A)
I felt that I was using a lot of nervous energy (S)
I was worried about situations in which I might panic and make a fool of myself (A)
I felt that I had nothing to look forward to (D)
I found myself getting agitated (S)
I found it difficult to relax (S)
I felt downhearted and blue (D)
I was intolerant of anything that kept me from getting on with what I was doing (S)
I felt I was close to panic (A)
I was unable to become enthusiastic about anything (D)
I felt I was not much of a person (D)
I felt that I was rather touchy (S)
I was aware of the action of my heart in the absence of physical exertion (eg. sense of heart rate increase, heart missing a beat) (A)
I felt scared without any good reason (A)
I felt that life was meaningless (D)

PCS Questionnaire

Everyone experiences painful situations at some point in their lives. Such experiences may include headaches, tooth pain, joint or muscle pain. People are often exposed to situations that may cause pain such as illness, injury, dental procedures or surgery. We are interested in the types of thoughts and feelings that you have when you are in pain. Listed below are 13 statements describing different thoughts and feelings that may be associated with pain. Using the following scale, please indicate the degree to which you have these thoughts and feelings when you experience pain.

0 = not at all
1 = to a slight degree
2 = to a moderate degree
3 = to a great degree
4 = all the time

When I’m in pain...

	0	1	2	3	4
I worry all the time about whether the pain will end (H)
I feel I can’t go on (H)
It’s terrible & I think it's never going to get any better (H)
It’s awful and I feel that it overwhelms me (H)
I feel I can’t stand it anymore (H)
I become afraid that the pain will get worse (M)
I keep thinking of other painful events (M)
I anxiously want the pain to go away (R)
I can’t seem to keep it our of my mind (R)
I keep thinking about how much it hurts (R)
I keep thinking about how badly I want the pain to stop (R)
There’s nothing I can do to reduce the intensity of my pain (H)
I wonder whether something serious will happen (M)

TOTAL

Symptom Monitor & Pain Questionnaire

Client Information

Bladder Symptoms

Urination Frequency:

Fluid Intake in 24 hours:

Bowel History

Answer if applicable

Pain History

Medical History

Central Sensitization Inventory: Part A

Central Sensitization Inventory: Part B

DASS Questionnaire

PCS Questionnaire