Name *
Name
Date
Date
HISTORY
Date of last pap smear
Date of last pap smear
Did you have any trouble healing after delivery?
Do you have any history of sexual abuse or trauma?
Are you having regular periods/menstrual cycles?
Do you have frequent urinary tract infections?
Pain
Do you have pain with:
Test Results
Bladder Symptoms
Do you lose urine when you:
Do you...
Bowel symptoms
Do you...