Vesicovaginal Fistula Evaluation Form
Complete this structured clinical assessment for vesicovaginal fistula evaluation.
Patient Name or Identifier
*
Age
*
Sex at Birth
*
Female
Male
Intersex
Obstetric/Gynecologic History
*
Presenting Symptoms
*
Suspected Onset or Duration of Symptoms
Prior Pelvic Surgery or Childbirth-Related Injury
No prior surgery or injury
Prior pelvic surgery
Childbirth-related injury
Both surgery and injury
Other
Urinary Leakage Description
*
History of Infection or Other Related Symptoms
Clinician Notes / Next-Step Evaluation
Submit Evaluation
Should be Empty: