Please describe and specify date 1
Please describe and specify date 2
ache
6 Describe any previous treatmentsexercises 1
6 Describe any previous treatmentsexercises 2
Sitting greater than
Walking greater than
Standing greater than
undefined_2
8 What relieves your symptoms
9 What are your treatment goalsconcerns
Tests performed
undefined_3
Date of last gynecology exam
ActivityExercise
OtherDescribe
brain female organs bladderprostate bonesjoints andor abdominal organs 1
brain female organs bladderprostate bonesjoints andor abdominal organs 2
YN Childbirth vaginal deliveries
YN Episiotomy
YN CSection
YN Menopause when
YN Difficult Childbirth
Medications 1
Medications 2
1 Frequency of urination awake hours
times per day sleep hours
3 Frequency of bowel movements
times per day
describe 1
describe 2
activity etc 1
activity etc 2
underwear wets outerwear etc 1
underwear wets outerwear etc 2
Date_2
Patient Name
Standing Greater Than Check Box Yes
Walking Greater Than Check Box Yes
Sitting Greater Than Check Box Yes
With Triggers Check Box Yes
Changing Positions Check Box Yes
Light Activity Check Box Yes
Vigorous Activity Check Box Yes
With Sexual Activity Check Box Yes
With Cough / Sneeze Check Box Yes
With Laughing / Yelling Check Box Yes
With Lifting / Bending Check Box Yes
With Cold Weather Check Box Yes
With Nervous / Anxiety Check Box Yes
No activity affects this check box Yes
Other Check Box Yes
Name
Age
Date
Incident / Injury Dropdown ---YES
Dropdown17 ---1-2 days / week3-4 days / week5+ days / weekNone
Check Box Cancer Yes
Check Box Heart Problems Yes
Check Box High Blood Pressure Yes
Check Box Ankel Swelling Yes
Check Box Anemia Yes
Check Box Low Back Pain Yes
Check Box SI Joint / Tailbone Pain Yes
Check Box Osteoporosis Yes
Check Box Fibromyalgia Yes
Check Box Rheumatoid Arthritis Yes
Check Box Allergiest (list below) Yes
Check Box Hypothyroidism Yes
Check Box Headaches Yes
Check Box Irritable Bowel Syndrome Yes
Check Box STD Yes
Check Box Physical or Sexual Abuse Yes
Check Box Childhood Bladder Problems Yes
Check Box Depression Yes
Check Box Anorexia / Bulimia Yes
Check Box Pelvic Pain Yes
Check Box Smoking History Yes
Check Box Other Yes
Check Box Stroke Yes
Check Box Multiple Sclerosis Yes
Dropdown25 ---NY
Check Box Choose Yes
Check Box Refuse Yes
Check Box Small Yes
Check Box Medium Yes
Check Box Large Yes
Place A Check Next to All That Apply Below
Check Box Same Yes
Check Box Getting Worse Yes
Check Box Getting Better Yes
