Pelvic History Information

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Crestview Hills Center

DOB *
DOB
Which of the following best describes how your injury occurred *
Date of last pelvic examination
Date of last pelvic examination
Date of last urinalysis
Date of last urinalysis
Incontinence
Do you leak if you: (check all that apply)
Toileting
Bowel Symptoms
Most common stool consistency
Daily Fluid Intake
History
Female Only Section
Date of last pap smear
Date of last pap smear
Did you have any complications during pregnancy? (check all that apply)
Did you have any complications after your pregnancy? (check all that apply)
Do you ever have a falling out feeling? (check all that apply)
Pain
Do you have pain with: (check all that apply)
General