eKonsey

Patient Information

Full Name *

Age *

Height

Weight

menstruation

Yes

No

What are your complaints?

Do you have a feeling of fullness or pressure in the groin area?

Is there a palpable swelling protruding from the vagina?

Do you have a feeling like something is falling out of your vagina?

Do your complaints worsen while walking and standing?

Do you have difficulty in urinating?

Do you have pain in the lower back (tail end) area?

Do you feel discomfort during intercourse?

Constipation (hard and small stools, not having daily bowel movements)

Do you have vaginal bleeding or spotting?

Is there a vaginal discharge?

Urinary incontinence

Does the palpable swelling in the vagina disappear while lying on your back?

Do you feel a need to strain while urinating?

Not being able to empty the bladder easily

Still needing to go to the toilet just after emptying the bladder.

When did your first complaint start?

When did your symptoms start?

Write your story about your illness.

Please inform us about the history of your illness:

How many births did you give?

How many babies have you had?

Sagging severity

Severity of your prolapse

I feel a mild prolapse.

There is a swelling drooping from the vagina but it is not bothersome.

There is a significant prolapse but I don't have any complaints.

Prolapse is annoying, I can't sit and palpable mass is very big.

The palpable swelling is immense, nearly all my organs are bulging out.

Do you have a known disease? State your illnesses.

Do you have any known diseases? Please indicate them:

Chronic constipation, COPD, asthma: Do you suffer from chronic constipation, chronic obstructive pulmonary disease (COPD) and/or asthma? (specify)

Chronic constipation, COPD, asthma: Do you have chronic constipation, chronic obstructive pulmonary disease (COPD) and/or asthma? Please indicate.

Write down any surgeries you have had, if any.

Previous surgeries (if any):

Write down the medications you use regularly (with their dosages).

Please state the medications you take on a regular basis (with doses)

Have you had any previous treatment for this disease?

Did you receive any treatments for this disease before?

Exercises for strengthening pelvic floor

Kegel exercises

Sports such as Pilates

Having a plastic device placed into the vagina to prevent bulging

Did you undergo a surgical procedure?

Imaging (Radiology) Reports

Urinary Tract Ultrasonography

Pelvic MRI

Complete MRI scan of the Abdomen

Laboratory / Biochemistry Examinations

Complete urinalysis report

Urodynamic Testing Result

Biochemistry Report

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Bladder Prolapse