Fecal Incontinence

Patient history of fecal incontinence

Name

DOB

Today’s date

Duration of fecal incontinence

Type of incontinence

Smear Complete Loss

Urgency

Yes No Sometimes

Number of bowel movements per day

Able to feel urge to defecate

Yes No

Stool consistency

Watery Loose Formed Hard

Type of Incontinence and Frequency

Solid

Liquid

Gas

Wears pads

Alteration in lifestyle

History of anorectal surgery

Yes No

If yes, please give description

History of trauma to perineum

Yes No

If yes, please give description

Neurological impairment

Yes No

If yes, please give description

Spinal cord injury

Yes No

If yes, which level

Diabetes

Yes No

Type

Impotent

Yes No

Radiation therapy to perineum

Yes No

If yes, please give description

Patient history of urinary incontinence

Urinary frequency

Yes No

How often

Urinary urgency

Yes No

Incontinence with urgency

Yes No

Incontinence with coughing/ sneezing/ exercise

Yes No

Number of pads per day

Difficulty starting urine flow

Yes No

Difficulty maintaining flow

Yes No

History of bladder infections

Yes No

Comments

Obstetric history

Number of Pregnancies

Delivery History 1

Term Delivery

Vaginal

Episiotomy or tear

Pre-term delivery

C-section

Forceps or vacuum

Delivery History 2

Term Delivery

Vaginal

Episiotomy or tear

Pre-term delivery

C-section

Forceps or vacuum

Delivery History 3

Term Delivery

Vaginal

Episiotomy or tear

Pre-term delivery

C-section

Forceps or vacuum

Delivery History 4

Term Delivery

Vaginal

Episiotomy or tear

Pre-term delivery

C-section

Forceps or vacuum

Delivery History 5

Term Delivery

Vaginal

Episiotomy or tear

Pre-term delivery

C-section

Forceps or vacuum

Comments

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