History Form For Patients With Interstitial Cystitis If you have urinary frequency or pain, please fill this out prior to your visit.
When was your bladder last “normal”?

How frequently do you go to the bathroom during the day? Every ___________ minutes.
How many times do you get up at night to urinate? _____________________
On the average, how many times do you urinate in twenty-four hours? ______________
Please list all medications that you are currently taking along with their dosages. We need to know
every medication whether it is an alternative medicine, an herbal medicine, an over the counter
medicine, or a prescription medicine.
Do you have any bowel problems? Do you have diarrhea? ___Do you have constipation?
_____ Have you seen a GI doctor in the last year? ______ Have you had a Colonoscopy in the last
two years? ______
Do you have any gynecologic problems? ________ Does your pain occur at a particular time during
your menstrual cycle? __________ When was your last monthly period? ______ Could you be
pregnant? ________ When was your last visit to the gynecologist? _______When was your last
pelvic ultrasound? ____________
Do you have pelvic pain? ________ If so, where? _____________________________
Please try to calibrate the degree of your pelvic pain. #1=minor #10=very bad. Your pain today is
what # on the scale? _______ Your pain is usually what # on the scale? ______ How many days per
month do you have the pain? ________
Does your bladder hurt when it is full? __________
Has any prior treatment ever helped you? _________________________________
Has any prior treatment ever made your condition worse? ________________________
Have you ever had a potassium sensitivity test? ________Have you ever had a bladder biopsy?
Have you ever been diagnosed with Depression ________ Fibromyalgia ___________
Headaches ________ Irritable Bowel Syndrome ___________ Gluten sensitivity ____
History Form For Patients With Interstitial Cystitis Please fill out this form and circle any treatment that you have ever had
Helped Me Hurt Me Had No Effect How long did you use this therapy?
History Form For Patients With Interstitial Cystitis
Please list any surgeries that you have ever had, particularly involving the bladder, GYN
organs or colon.

1. __________________________________________________________________ 2. __________________________________________________________________ 3. __________________________________________________________________ 4. __________________________________________________________________ 5. __________________________________________________________________ 6. __________________________________________________________________ 7. __________________________________________________________________ 8. __________________________________________________________________ 9. __________________________________________________________________ 10. __________________________________________________________________


Home whitening instructions and consent form Patient’s Name :____________________________ Date :____________________________________ We are planning to whiten your teeth using carbamide peroxide solution. Please read the following instructions carefully. The active ingredient is carbamide peroxide in a glycerine base. If you know of any allergy or are aware of an adverse reaction

Who | dispatch from the field

17 June 2009 Dispatch from the field Katutura State Hospital, Windhoek, Namibia WINDHOEK, Namibia—In his last mission asDirector of the WHO HIV/AIDS Department, DrKevin De Cock visited the Katutura State Hospitalin Windhoek, Namibia, where he praised effortsby national authorities and health-care providersto expand antiretroviral treatment (ART) to thosein need. “Here’s a very large

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