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Intake Forms / Self-Assessment Tools
Intake Forms
Please click on the following links to view and print your Urogynecology New Visit Intake Forms. Please complete prior to your first visit appointment at Mountain States Urogynecology. The Bladder Diary is also useful for documenting a change (improvement or worsening) of bladder symptoms prior to any office visit or for your own record-keeping.
Self-Assessment Tools
This section includes numerous tests given to patients with incontinence and other pelvic floor disorders to both screen for problems and to assess the severity of the problem to the patient.
Answer these questions to determine what type of Urinary incontinence is bothersome to you:
Answer these questions to determine if fecal incontinence is bothersome to you:
Click on one of the items below and complete the questions to assess the severity or impact of the condition on your life
- Urinary Incontinence
- Pelvic Organ Prolapse and Bowel Problems
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