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Where did you find us?
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Which specialists do you see?
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Who referred you?
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Do you use online scheduling?
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Want access to online portal?
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Anything special we need to know
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YOUR MEDICAL HISTORY
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Your Past and Current Diagnosis
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Past Medical History Freewrite
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Your Past Surgical History
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Comments
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Your Childhood Illnesses
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Comments
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Your Past Immunizations
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Comments
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Date of your last Physical Exam
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Your Primary Care Contact Information
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Date and Results of your last PAP smear
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Date and Results of your last Colon Screening
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Date and Results of your last Breast Screening
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Your Family History
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Your Father's Medical History
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Comments
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Your Sibling(s)' Medical History
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Comments
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Your Mother's Medical History
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Comments
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Your Grandparent's Medical History
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Comments
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Your Children(s)' Medical History
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Comments
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YOUR SOCIAL HISTORY
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Your Marital Status
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Any Potential Environmental Pathogen Exposure
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Your Living Arrangements
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Comments
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Your Sexual History
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Comments
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Your Occupation/Work
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Comments
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Your Caffeine Intake
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Your Alcohol Intake
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Any Other Substance Use
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Describe Your Diet
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PLEASE SELECT ANY CURRENT SYMPTOMS
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Yes I Have General Physical Symptoms
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Please Select Your General Physical Symptoms
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General Physical Symptoms Comments
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Yes I Have Skin Symptoms
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Please Select Your Skin Symptoms
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Skin Comments
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Yes I Have Head/Ears/Nose/Throat Symptoms
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Please Select Your Head/Ears/Nose Symptoms
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Head/Ears/Nose Symptoms Comments
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Yes I Have Neck Symptoms
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Please Select Your Neck Symptoms
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Neck Comments
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Yes I Have Breast Symptoms
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Please Select Your Breasts Symptoms
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Breasts Comments
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Yes I Have Cardiovascular Symptoms
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Please Select Your Cardiovascular Symptoms
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Cardiovascular Comments
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Yes I Have Respiratory Symptoms
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Please Select Your Respiratory Symptoms
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Respiratory Comments
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Yes I Have Gastrointestinal Symptoms
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Plese Select Your Gastrointestinal Symptoms
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Gastrointestinal Comments
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Yes I Have Urinary/Bladder Symptoms
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Please Select Your Urinary/Bladder Symptoms
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Urinary/Bladder Comments
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Yes I Have Female Genital Symptoms
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Genital (Female) Comments
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Please Select Your Genital (Female) Symptoms
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Yes I Have Male Genital Symptoms
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Please Select Your Genital (Male) Symptoms
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Genital (Male) Comments
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Yes I Have Peripheral Vascular Symptoms
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Please Select Your Peripheral Vascular Symptoms
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Periph. Vasc. Comments
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Yes I Have Musculoskeletal Symptoms
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Please Select Your Musculoskeletal Symptoms
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Musculoskeletal Comments
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Yes I have Neurological Symptoms
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Please Select Your Neurological Symptoms
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Neurological Comments
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Yes I Have General Endocrine Symptoms
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Please Select Your General Endocrine Symptoms
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Endocrine Comments
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Yes I Have Adrenal Dysfunction Symptoms
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Please Select Your Adrenal Dysfunction Symptoms
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Adrenal Dysfunction Comments
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Yes I Have Insulin Dysfunction Symtoms
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Please Select Your Insulin Dysfunction Symtoms
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Insulin Dysfunction Comments
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Yes I Have Thyroid Dysfunction Symptoms
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Please Select Your Thyroid Dysfunction Symptoms
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Thyroid Dysfunction Comments
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Yes I Have Female Sexual Hormone Dysfunction
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Select Your Female Sexual Hormone Dysfunction
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Female Sexual Hormone Comments
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Yes I Have Male Sexual Hormone Dysfunction
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Select Your Male Sexual Hormone Dysfunction
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Male Sexual HormoneComment
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Yes I Have Psychiatric Symptoms
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Please Select Your Psychiatric Symptoms
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Psychiatric Comments
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Yes I Have Inflammation Symptoms
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Please Select Your Inflammation Symptoms
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Inflammation Symptoms Comments
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Yes I Have Oxidative Stress Symptoms
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Please Select Your Oxidative Stress Symptoms
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Oxidative Stress Comments
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Yes I Have Suboptimal Dopamine Level Symptoms
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Select Your Suboptimal Dopamine Level Symptoms
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Suboptimal Dopamine Level Comments
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Yes I Have Suboptimal Serotonin Level Symptoms
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Select Your Suboptimal Serotonin Level Symptoms
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Suboptimal Serotonin Level Comments
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Yes I Have Suboptimal Gaba Level Symptoms
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Select Your Suboptimal Gaba Level Symptoms
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Suboptimal Gaba Level Comments
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Yes I Have Suboptimal Methylation Symptoms
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Select Your Suboptimal Methylation Symptoms
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Suboptimal Methylation Comments
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Yes I Have Suboptimal Vitamin D Symptoms
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Please Select Your Suboptimal Vitamin D Symptoms
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Suboptimal Vitamin D Comments
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Yes I have Suboptimal Magnesium Symptoms
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Please Select Your Suboptimal Magnesium Symptoms
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Suboptimal Magnesium Comments
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Yes I Have Suboptimal Zinc Symptoms
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Please Select Your Suboptimal Zinc Symptoms
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Suboptimal Zinc Comments
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Yes I have Pelvic Pain and or Vaginal Pain
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Please Select Your Pain Symptoms
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What do you think is causing your pain?
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How long have you had this pain?
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Yes there is an event associated with the onset.
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Describe Event Associated with the onset of pain
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Please Rate Your Pain
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I Have No Pain
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No Pain
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HURTS Just a Little Bit
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HURT Just a Little Bit More
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HURTS Even More
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HURST a Lot
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HURTS as Much as You Can Imagine
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Confidential Patient Questionnaire
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Description
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Have you been sexually active in the past?
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Are your currently sexually active?
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Pelvic Health Screening Questionnaire
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Surgical History
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Surgical History Other
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OB/GYN History
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OB/GYN History Other
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Bladder/Bowel History
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Bladder/Bowel History Other
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Pelvic Symptoms Questionnaire
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Questionnaire for bladder/bowel Incontinence
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When did your bowel/bladder symptoms begin
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Describe Symptoms
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Specify Incident and Date
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Why or How?
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Was your first episode related to a incident
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Are symptoms changing?
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Frequency of urination during the Day
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Frequency of Urination during the night
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Amount of Urine Passed
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Frequency of Bowel Movement
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Fluid Intake
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Pelvic/Organ Pressure
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Bladder Leakage Episodes
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Average Urine Leakage
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Bowel Leakage Episodes
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Protection Used other- description
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Average Stool Leakage
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Protection Used
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Activities related to symptoms description
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Average Pad Changes in 24 hours?
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Activities related to symptoms
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Rate your feelings of severity
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How long can you delay urge?
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Frequency of BM - other desciption
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After urge how long can you delay BM?
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