Name
Age
Date
1. Describe the problem that brought you here [LINE-1]
1. Describe the problem that brought you here [LINE-2]
2. When did your problem first begin
3. Was your first episode of the problem related to a specific incident/injury? Yes/No —Please choose an option—YES
Please describe and specify date
4. Since that time/injury is it: ______ same ______ getting worse ______ getting better
Same Yes
Getting Worse Yes
Getting Better Yes
5. If pain is present, describe pain (ie. constant, burning, intermittent ache __________
6. Describe any previous treatments exercises [LINE-1]
6. Describe any previous treatments exercises [LINE-2]
7. Check activities that may aggravate your symptoms (any/all that apply)
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
Sitting greater than ____ minutes
Walking greater than ____ minutes
Standing greater than ____ minutes
Other:
8. What relieves your symptoms
9. What are your treatment goals concerns
Date of last gynecology exam: ____________ Tests performed: ____________
Date of last gynecology exam:
Tests performed:
Activity/Exercise: —Please choose an option—1-2 days / week3-4 days / week5+ days / weekNone
Have you ever had or experienced any of the following?
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
Surgical/Procedure History: Please list and describe procedures to the back/spine, brain, female organs, bladder/prostate, bones/joints, and/or abdominal organs: [LINE-1]
Surgical/Procedure History: Please list and describe procedures to the back/spine, brain, female organs, bladder/prostate, bones/joints, and/or abdominal organs: [LINE-2]
Childbirth vaginal deliveries
Episiotomy
CSection
Menopause When
Difficult Childbirth
Medications [LINE-1]
Medications [LINE-2]
YES/ NO —Please choose an option—NY
1. Frequency of urination: awake hours = ________ times per day, sleep hours = ________ times per night
Awake hours =
Sleep hours =
2. The usual amount of urine passed is: _______ small _______ medium _______ large
Small Yes
Medium Yes
Large Yes
3. Frequency of bowel movements ________ times per day, ________ times per week, or describe ________
times per day
times per week
describe
4. Average fluid intake for the day? (include water and other drinks)
5. Describe the feeling if you have “falling out” feeling of your organs/prolapse/or pelvic heaviness. Specify whether it is occasionally, with prolonged standing, activity, etc.) [LINE-1]
5. Describe the feeling if you have “falling out” feeling of your organs/prolapse/or pelvic heaviness. Specify whether it is occasionally, with prolonged standing, activity, etc.) [LINE-2]
6. If you are having incontinence/leakage, how many times a day or week do you leak, or is it only with physical exertion/cough? [LINE-1]
6. If you are having incontinence/leakage, how many times a day or week do you leak, or is it only with physical exertion/cough? [LINE-2]
7. If you have leakage, how much do you leak on average? (ie. a few drops, wets underwear, wets outerwear, etc.) [LINE-1]
7. If you have leakage, how much do you leak on average? (ie. a few drops, wets underwear, wets outerwear, etc.) [LINE-2]
I acknowledge and understand that I have been referred for evaluation and treatment of pelvic floor dysfunction. Pelvic floor dysfunctions include, but are not limited to, urinary or fecal incontinence; difficulty with bowel, bladder, or sexual functions; painful scars after childbirth or surgery; persistent sacroiliac or low back pain; or pelvic pain conditions.
I understand that to evaluate my condition it may be necessary, initially and periodically, to have my therapist perform an internal pelvic floor muscle examination. This examination is performed by observing and/or palpating the perineal region including the vagina and/or rectum. This evaluation will assess skin condition, reflexes, muscle tone, length, strength and endurance, scar mobility, and function of the pelvic floor region. Such evaluation may include vaginal or rectal sensors for muscle biofeedback.
Treatment may include, but not be limited to, the following: observation, palpation, use of vaginal weights, vaginal or rectal sensors for biofeedback and/or electrical stimulation, ultrasound, heat, cold, stretching and strengthening exercises, soft tissue and/or joint mobilization, and educational instruction.
I understand that in order for therapy to be effective, I must come as scheduled unless there are unusual circumstances that prevent me from attending therapy. I agree to cooperate with and carry out the home program assigned to me. If I have difficulty with any part of my treatment program, I will discuss it with my therapist.
1. The purpose, risks, and benefits of this evaluation have been explained to me.
2. I understand that I can terminate the procedure at any time.
3. I understand that I am responsible for immediately telling the examiner if I am having any discomfort or unusual symptoms during the evaluation.
4. I have the option of having a second person present in the room during the procedure and choose refuse this option.
Check Box Choose Yes
Check Box Refuse Yes
Patient Name
Patient Signature:
Signature of Parent or Guardian (if applicable):
