H&P CC/HPI UROGYN Medical Form

Bladder/Urethral Pain	Quality • • •
Severity • • •	Duration • • •
Timing • • •	Alleviating Factors • • •
Aggravating Factors • • •	Associated Symptoms • • •
Comments

Bowel Complaints/Fecal Incontinence	Quality • • •
Severity • • •	Duration • • •
Timing • • •	Alleviating factors • • •
Aggravating Factors • • •	Associated Symptoms • • •
Comments

Chronic Constipation	Quality • • •
Severity • • •	Duration • • •
Timing • • •	Alleviating Factors • • •
Aggravating Factors • • •	Associated Symptoms • • •
Comments

Hematuria	Quality • • •
Severity • • •	Timing • • •
Context • • •	Alleviating Factors • • •
Associated Symptoms • • •	Comments

Interstim Follow-up	Comments

Overactive Bladder	Quality • • •
Severity • • •	Duration • • •
Timing • • •	Alleviating Factors • • •
Aggravating Factors • • •	Associated Symptoms • • •
Comments

OAB Botox Follow-up	Comments

OAB Medication Follow-up	Comments

Pessary Check	Comments

Pelvic Pain	Quality • • •
Severity • • •	Duration • • •
Timing • • •	Context • • •
Aggravating Factors • • •	Alleviating Factors • • •
Associated Symptoms • • •	Comments

Presurgery	Comments

Post-op Visit	Comments

Physical Therapy Follow-up	Comments

Prolapse Symptoms	Quality • • •
Severity • • •	Duration • • •
Timing • • •	Associated Symptoms • • •
Comments

Recurrent UTI	Severity • • •
Duration • • •	Timing • • •
Aggravating Factors • • •	Alleviating Factors • • •
Associated Symptoms • • •	Comments

Urinary Incontinence	Type of Incontinence
Quality • • •	Severity • • •
Duration • • •	Aggravating Factors • • •
Alleviating Factors • • •	Associated Symptoms • • •
Comments

Urotalk	Comments

Nurse Practitioner

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Published: Sept. 14, 2017, 1:15 p.m.
Doctor: Dr. History Physical
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H&P CC/HPI UROGYN Medical Form

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