DATE CONTINENCE ASSESSMENT CLINICAL HISTORY FEMALE

CONTINENCE THERAPISTS ONLY

Urogynaecology Clinical History Form

Continence Assessment Clinical History - Female

GYNAECOLOGICAL HISTORY

CONTINENCE PROBLEMS AFTER STROKE IT IS COMMON FOR PEOPLE
DAILY HABITS AND URINARY INCONTINENCE EFFECTS OF DAILY MANY
DATE CONTINENCE ASSESSMENT CLINICAL HISTORY FEMALE

DISTRICT NURSING CONTINENCE ADVISORY SERVICE PHONE (03 684 1558
FORMULARY FOR INCONTINENCEMOISTURE SKIN PROTECTION GENERIC CATEGORY FUNCTION
GUIDANCE ON CONTINENCE AND INTIMATE CARE IN EARLY YEARS

DATE CONTINENCE ASSESSMENT CLINICAL HISTORY FEMALE

Date: ______/______/______

Presenting complaint(s) and duration:

__________________________________________________________________________________________

Duration of stress leakage (if applicable):

Duration of urge leakage (if applicable):

SELF REPORTED URINE LEAKAGE

Urine loss with:

Cough:	 Yes	 No	Sneeze:				 Yes	 No
Laugh/giggle:	 Yes	 No	Walk:				 Yes	 No
Run:	 Yes	 No	Jump:				 Yes	 No
Downhill/steps:	 Yes	 No	Lift/push/pull:				 Yes	 No
Change of position:	 Yes	 No	Sexual intercourse:				 Yes	 No
With urge:	 Yes	 No	Unconscious leakage:				 Yes	 No
Other (please give details):

Nocturnal enuresis (bed wet when wakes):				 Yes	 No
Association with menstrual cycle:				 Yes	 No	 Not applicable

Frequency/urge triggers:

Running water:	 Yes	 No	Cold weather:	 Yes	 No
Key in lock:	 Yes	 No	Change of positions:	 Yes	 No
Other (please give details):

Incontinence product(s):  Yes  No (if yes, give details below)

Does leakage occur (tick one box only):

 More than once a day?

 Not every day but more than twice a week?

 Not every week but more than twice a month?

 Less than once a month?

What is the amount of each leak (tick more than on box if amount varies):

 A drop or few drops?	 Enough to run down legs?
 Wets pants or pad?	 Bladder completely empties?
 Wets outer clothing?	 Leaking all the time?

SELF REPORTED URINARY SYMPTOMS

Frequency (<2 hourly voids):	 Yes	 No
Nocturia (>1 per night):	 Yes	 No
Urgency:	 Yes	 No	[If yes, continence therapists only: urge is imperative/suprapubic/urethral]

Able to defer void:	 Yes	 No	If yes, how long?

Dysuria:	 Yes	 No
Haematuria:	 Yes	 No
Pain suggestive of urinary disorder:	 Yes	 No	If yes, details:

History or UTI or cystitis:	 Yes	 No	If yes, details (including frequency of episodes and treatment):

SELF REPORTED VOIDING SYMPTOMS

Desire to void:  Yes  No Hesitancy:  Yes  No

Interrupted stream:  Yes  No Small voids:  Yes  No

Strain to void:  Yes  No Manual expression:  Yes  No

Revoid (<½ hr):  Yes  No Terminal dribbling:  Yes  No

URINARY HISTORY

History of incontinence:

Childhood:  No  Yes

Pregnancy:  No  Yes

Postnatal:  No  Yes

Previous conservative management:

Previous medical management:

Previous incontinence surgery:

Vaginal: procedure(s): ___________________ date(s): ___________________

Retropubic: procedure(s): ___________________ date(s): ___________________

Other: procedure(s): ___________________ date(s): ___________________

BOWEL HABIT

Usual bowel pattern:

Use of laxatives/diet/other products (please circle and give details):


Hold flatus:	 Yes	 No	Urgency:	 Yes	 No	Problems initiating:	 Yes	 No
Problems completing:	 Yes	 No	Straining:	 Yes	 No	Perineal support:	 Yes	 No
Manual evacuation:	 Yes	 No	Soiling:	 Yes	 No	Problems initiating:	 Yes	 No

[Continence therapists only: details of voiding and defecation positions if relevant]

OBSTETRIC HISTORY

No. of pregnancies >20/40:		No. of pregnancies <20/40 (if relevant):

Types of delivery, number, complications of note:

Family completed?	 Yes  No

Cycle:				LMP:

Menopause:	 Yes	 No	If yes, age ______

Sexually active:	 Yes	 No	If yes, contraception:

Dyspareunia:	 Yes	 No	If yes, details:

Prolapse symptoms:	 Yes	 No	If yes, details:

Normal smear history:	 Yes	 No	If no, details:

Date of last smear:				Mammography:

Other:

GENERAL HEALTH

Medical history:

Glaucoma?  Yes  No

Surgical history (including gynaecological, excluding incontinence):

Family history:

Symptoms review:

CNS:

CVS:

RESP:

GIT:

MUSCULOSKELETAL:

Drugs and allergies:

Vaginal oestrogens?  Yes  No If yes, name and dosage

Hormone replacement therapy?  Yes  No If yes, name and dosage

Anticholinergics for urinary symptoms?  Yes  No If yes, name and dosage

LIFESTYLE

Occupation: Living circumstances:

Social activities: Exercise/activity/recreation:

Mobility (if impaired): Smoking:  Yes  No If yes, number per day:

Fluid intake (including type and amount of caffeine):

ETHNICITY (Please ask each woman to complete, or assist where appropriate)

Please tick as many boxes as you need to show which ethnic group(s) you belong to:

 NZ Maori  Samoan  Cook Island Maori  Other

 NZ European or Pakeha  Tongan  Chinese

 Other European  Nuiean  Indian

PHYSICAL EXAMINATION

Height (cm):

Weight (kg):

CVS:

BP:

Pulse:

 Normal

 Abnormal, give details

RESP:

 Normal

 Abnormal, give details

NEURO:

Lower limb power:

 Normal

 Abnormal, give details

Lower limb sensation:

 Normal

 Abnormal, give details

Lower limb reflexes:

 Normal

 Abnormal, give details

Anal/perineal sensation:

 Normal

 Abnormal, give details

Anal reflex:

 Normal

 Abnormal, give details

ABDOMINAL:

 Normal

 Abnormal, give details

RECTAL:

 Normal

 Abnormal, give details

PELVIC:

Nil

Minimal

Moderate

Severe (please circle number)

Atrophic changes:

Prolapse:

Nil

Stage I

Stage II

Stage III

Stage IV (please circle number)

Urethrocele:

Cystocele:

Uterine:

Vault:

Enterocele:

Rectocele:

Position in which examined:

[KEY: Nil – no prolapse demonstrated with maximal valsalva; Stage I – most distal position of prolapse (DPP) >1cm above plane of hymen; Stage II – DPP <1cm above or below plane of hymen; Stage III – DPP >1cm below plane of hymen, but <2cm of total vaginal length; Stage IV – complete eversion of total vaginal length or lower genital tract]

Urethra:

Cervix:

Smear taken:

 Yes  No

Uterus:

Adenexae:

Demonstrable leakage:

 Yes  No

Voluntary pelvic floor muscle contraction:

 Yes  No

PHYSICAL EXAMINATION (CONTINENCE THERAPISTS ONLY)

Post void residual (ultrasound):

Able to interrupt stream:		 Yes			 No change		 Slowed

Perineal observation:
	Movement with valsalva:	 None			 Minimal	 Ballooning		 Leakage
	Movement with VPFMC:	 Cephalic			 Caudal	 Neither
	Vaginal/urethral wink:	 Yes			 No
	Anal wink:	 Yes			 No

Palpation:
	PFM symmetry at rest:
	PFM symmetry with contraction:

VPFMC:
	Accompanied by:	 Breath holding			 Abdominals		 Gluteals	 Hip adductors

	Grade (please circle):	0		Nil
		1		Flicker (with or without stretch)
		2		Weak (minimal lift or hold)
		3		Fair (definite lift)
		4		Good (definite lift and hold)
		5		Strong (good lift and hold, repeatable)

	Number of repetitions:

	Length of hold:

	Contraction with cough:		 Reflex		 Voluntary		 None

SUMMARY OF TESTS AND INVESTIGATIONS

MSSU:

Urinary diary (see attached):

24 hour home pad test:

Pre test pad weight: ______ g + ______ g + ______ g = ______ g

Post test pad weight: ______ g + ______ g + ______ g = ______ g

Total pad weight gain: ______ g

.cm

Transperineal ultrasound findings:

Bladder neck descent:

Urodynamic findings:

Urodynamic stress incontinence:	 Yes	 No
Intrinsic sphincter deficiency:	 Yes	 No
Idiopathic detrusor overactivity:	 Yes	 No
Voiding dysfunction:	 Yes	 No
Other (please give details):

SUMMARY

Problem list

__________________________________________________________________________________________

Plan

__________________________________________________________________________________________

Type of product:

Amount of product:

Allowance received:

Informed consent for transperineal / vaginal / rectal examination (please delete if not appropriate)


Signature:		Date:	______/______/_______
	(Client)


Signature:		Date:	______/______/_______
	(Therapist)

ODHB 44428 V1 Issued 22/08/2007 Page 1 of 7

IMPORTANT CONTACT NUMBERS THE COMMUNITY EQUIPMENT AND CONTINENCE SERVICE
International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form

Tags: assessment clinical, female, clinical, history, assessment, continence