Thomas I.
Janicki MD
1611 South Green Rd.
Cleveland, Ohio 44121
800-891-5285
PATIENT HISTORY
PELVIC AND
ABDOMINAL PAIN
Please fax
this form to: 216-381-5975
Patient Name: ____________________________________________________
FirstMiddleLastDate
of Birth
Please describe your symptoms in your
own words: ______________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
What
is your age? ______, Were you
ever pregnant?YESNO
How many deliveries? _______Vaginal:
________C/Sections: ___________
How many miscarriages? ___________How
many terminations? ___________
How many ectopic pregnancies? _______________
Have you ever been treated for infertility?YESNO
Are you currently being treated for
infertility?YESNO
Do you use contraception?YESNOWhat
kind?______________________
How old were you when you had your first
period? _____
Are your periods regular?YESNO,
How often do they come? Every: ________________days
How many days do you bleed during your
menses? ________________
Are your periods painful?YESNO
Please
mark on the graph below any pain during your cycle and its relation to
the menstruation, use "1" for mild pain, "2" for moderate pain and "3"
for severe pain.
-3-2-1menses1234
5 6 7
<= days=>
What medication do you take for pain
during your menstrual period? _______________________________________________________________
Does the medication work?YESNO
What helps your pain? (meds, activity,
heating pad, etc.) ___________________
____________________________________________________________________________________________________________________
What makes your pain worse? ________________________________________
________________________________________________________________
Do you have pain not associated with
your period?YESNO
When does this pain appear? ________________________________________
Where is this pain located? __________________________________________
________________________________________________________________
What are the characteristics of this
pain? (sharp, burning, twisting, etc.) ________________________________________________________________
________________________________________________________________
What helps this pain? _______________________________________________
________________________________________________________________
What makes this pain worse? ________________________________________
________________________________________________________________
Do you have pain with sexual relations?YESNO
Is this pain? At
the opening of the vaginaYESNO
Inside
the vaginaYESNO
Deep
inside the pelvisYESNO
In
the lower abdomenYESNO
In
the backYESNO
In
the rectumYESNO
Is the pain associated with sexual relations
present:
During
the intercourseYESNO
After
the intercourseYESNO
Lasting
more than a couple hours after the intercourseYESNO
Lasting
for several days after the intercourseYESNO
Does the pain stops you from having
sexual relations?YESNO
Do you have pain when your bladder gets
full?YESNO
Do you have pain with bowel movements?YESNO
Does your pain get aggravated by:
LiftingYESNO
CoughingYESNO
SneezingYESNO
StrainingYESNO
JoggingYESNO
WalkingYESNO
PREVIOUS DIAGNOSTIC
EVALUATIONS AND TREATMENTS
Did you ever have any abdominal or pelvic
surgery, including laparoscopy?
YESNO
Please list them below:
1.__________________________________________________
2.__________________________________________________
3. __________________________________________________
4. __________________________________________________
5.__________________________________________________
What were the findings?
1.__________________________________________________
2.__________________________________________________
3. __________________________________________________
4. __________________________________________________
5.__________________________________________________
What surgical treatment did you receive?
1.__________________________________________________
2.__________________________________________________
3. __________________________________________________
4. __________________________________________________
5.__________________________________________________
Was surgical treatment successful in
relieving your pain?YESNO
________________________________________________________________
What medical treatment did you receive?
1.__________________________________________________
2.__________________________________________________
3. __________________________________________________
4. __________________________________________________
5.__________________________________________________
Was medical treatment successful in
relieving/controlling your pain?YESNO
________________________________________________________________
If you are presently being treated,
please describe your treatment:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Does your present treatmentEliminate
painYESNO
Control
painYESNO
Is
not helpingYESNO
Do
you suffer from:DepressionYESNO
AnxietyYESNO
Irritable
bowel diseaseYESNO
FibromyalgiaYESNO
Are you presently in supportive psychotherapy
because of:
DepressionYESNO
AnxietyYESNO
Chronic
painYESNO
Do you have any other medical conditions? (Diabetes, Hypertensions, etc.)
1.__________________________________________________
2.__________________________________________________
3. __________________________________________________
4. __________________________________________________
5.__________________________________________________
Please list all the medication you are
using regularly: ______________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Are you allergic to any medications?
___________________________________
________________________________________________________________________________________________________________________________