Forms and Documents
New Patient Form
The following forms are all required at your first visit. It takes a few minutes to fill out the forms accurately, so please complete prior to your visit. You can easily print from here. Please note, you must have adobe reader to read files.
We recognize that this is a lot of paperwork, and for that we apologize. Each form has a specific purpose that is outlined after the form.
- Medical History Form Designed by the doctors to provide the pertinent information needed to begin your care.
- Patient Information Form Necessary to start your chart and bill your insurance company.
- Consent for Treatment Form Mandated by law.
- Health form Required by Providence Hospital. It is part of the information that is automatically entered into your electronic chart.
- Meaningful use The term that is defined by the federal government. The information that is collected on this form is required for us to meet this measure. If we fail to meet this measure, we will have to pay a federally mandated financial penalty.
Please fill out the forms below if your are being seen for Prolapse or Incontinence. Prolapse includes cystocele (bladder dropping), rectocele (rectum falling) or enterocele (bowels coming down). All of them involve some kind of "bulge".
- PFDI Quality of life questionnaire that is designed to explore how the symptoms related to prolapse and incontinence effect your life.
- PFIQ Quality of life questionnaire that is designed to explore which symptoms are present.
- FSFI Quality of life questionnaire that looks at the relationship between prolapse, incontinence and sexual function.
The forms that follow can occasionally be useful to help with your specific condition. The PUF Questionnaire can predict the presence of Interstitial Cystitis. The Bladder Diary can be printed and filled out to get a better idea of your bladder function.