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Advanced Gynecologic Care Questionnaire

At NorthShore University HealthSystem, we are committed to your comprehensive healthcare, and partner with you to manage all of your healthcare concerns. We have found that many women’s gynecologic/pelvic health conditions are often overlooked, and do not want our patients to suffer in silence.

The following questionnaire was created to provide you with an opportunity to identify any concerns, and arrange an appointment with an appropriate women’s health provider.

Do you have any questions or concerns about:

1. Your periods (monthly cycle)—amount and timing of bleeding or any discomfort before or during periods?

2. Preventing, planning, or spacing pregnancies (including contraception)?

3. Urinating too frequently during the daytime or nighttime?

4. Accidental loss of urine ('incontinence', wetting your pants)?

5. Frequent bladder, kidney or urine infections?

6. Something bulging or falling out of the vaginal area ('dropped' uterus, bladder or vaginal supports)?

7. Something bulging or falling out of the anal area (where the stool comes out)?

8. Accidental loss of stool (fecal incontinence)?

9. Do you have any sexual concerns (pain, low desire, dissatisfaction) present consistently for more than 6 months that are currently distressing to you?

10. Accidental loss of stool (soiling your pants)?

11. Having been diagnosed as being menopausal and have had any vaginal bleeding?

12. Having menopausal symptoms (hot flashes or night sweats) that are impacting the quality of your life?

Please provide your information and our Advanced Gynecologic Care team will follow up on your concerns.

When you submit your questionnaire, we will route your submission to our Advanced Gynecologic Care team. You should expect a response within 1 business day.