PATIENT INFORMATION FORM

Name* :

Age* :

Gender* :
MaleFemale

Weight* :

Height* :

Location* :

Occupation* :

Contact number* :

Email* :

How do you feel leakage of Urine ?

a) Is there any Urgency of Urine?*

b) Is there more frequency of Urine?*

c) Is there any dribbling after Urination?*

d) Do you feel any bulge on your anterior wall of Vagina?*

e) Do you feel laxity of Pelvic floor muscles?*

f) Is there any History of Urinary Tract Infection (UTI)*

Any Medical History of :

Surgeries* :

Injuries* :

Child birth* :

Illness* :

Other diseases like Diabetes, Kidney Problem and any other Neurological problems?*

Social History* :

Smoking* :

Alcohol* :

Any other Addiction?*

How is Your Bowel Movement?*

Duration of the Problem?*

Past and Current problems with your Urinary System?*

Any Type of Treatment or Medicine which you are taking at present?*

Any Thing which you want to share?*

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