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 Treatments 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.
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
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