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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. Going through menopause—how often you bleed, or any symptoms that you have?

3. PAP Screening?

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

5. Breast health or your chances of getting breast cancer, or needing to schedule a mammogram?

6. Urinating too frequently during the daytime or nighttime?

7. Accidental loss of urine (incontinence)?

8. Frequent bladder, kidney or urine infections?

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

10. Pain, discomfort or dissatisfaction with sexual activity?

11. Infections related to having sex (sexually transmitted disease, STD)?

12. Vaginal discharge, odor, soreness, itching or rash?

13. Pain or discomfort in the lower part of your abdomen, pelvis or vaginal area?

14. Straining too hard to have a bowel movement, or being constipated?

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

16. Pain or discomfort in the anus or rectum (where the stool comes out)?

17. Other bowel problems, or questions about your risk of colon cancer, or needing colonoscopy?

18. A family history of female reproductive cancer?

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.