Download Pelvic Health Physiotherapy Intake Form Name: Date:

Pelvic Health Physiotherapy Intake Form Name: _________________________________________ Date: _________________________________________ Occupation: ___________________________________ Hobbies: _____________________________________ Please describe your primary complaints and what you are hoping to achieve from pelvic health physiotherapy: 1. ______________________________________________________________________________________________________________ 2. ______________________________________________________________________________________________________________ When did it start? ____________________________________________________________________________________________ What do you think is causing the issue? ___________________________________________________________________ What seems to aggravate the problem? ___________________________________________________________________ Medical History Abdominal Surgery (date): _________________________________________________________________________________ Pelvic Surgery (date): _______________________________________________________________________________________ Urinary Tract Infection (UTI): ☐ yes ☐ no Last UTI: ____________________ Smoking: ☐ yes ☐ no Chronic cough: ☐ yes ☐ no Neck problems: ☐ yes ☐ no Back problems: ☐ yes ☐ no Height: ________ Weight: _______ Current medications: ________________________________________________________________________________________ Allergies: _____________________________________________________________________________________________________ Have you ever been diagnosed with or thought you may have any of the following conditions? ☐ Vulvodynia ☐ Pudendal Neuralgia ☐ Endometriosis
☐ Vestibulodynia ☐ Levator Ani Syndrome ☐ Interstitial Cystitis
☐ Vaginismus ☐ Coccydynia ☐ Uterine Fibroids
☐ Dyspareunia ☐ Urethral Syndrome ☐ Anxiety/Depression When was your last physical? _______________________ Findings? ___________________________________________ Genealogical and Sexual History (Women): # Pregnancies: _______ # Births: _______ # Vaginal delivery: _______ # C-­‐section delivery: _______ Wt of heaviest baby: ____ lbs ____ oz Length of pushing: _________ Date of last delivery: _______________ Forceps? ☐ yes ☐ no Tears? ☐ yes ☐ no Episiotomy? ☐ yes ☐ no HRT? ☐ yes ☐ no Last pap: _____________________ Normal? ☐ yes ☐ no Birth control method: __________________________ Sexually active? ☐ yes ☐ no Difficulty achieving orgasm: ☐ yes ☐ no Pain with sex? ☐ yes ☐ no Penetration? ☐ Thrusting? ☐ Post-­‐orgasm? ☐ Other: ______________ Have you ever had a bad experience with sex? (forceful, non-­‐consensual, inappropriate or unwelcome touching) ☐ yes ☐ no Please describe to your level of comfort: ________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ Genealogical and Sexual History (Men): Have you every experienced erectile dysfunction? ☐ yes ☐ no Date: ______________ Have you ever had an abnormal prostate exam? ☐ yes ☐ no Date: ____________ Last PSA Score: _____ Have you been diagnosed with prostatitis in any form? ☐ yes ☐ no Date: ______________ Have you had a vasectomy? ☐ yes ☐ no Date: ______________ Sexually active? ☐ yes ☐ no Pain with sex? ☐ yes ☐ no Satisfactory ejaculation? ☐ yes ☐ no Painful erections? ☐ yes ☐ no Premature ejaculation? ☐ yes ☐ no Have you ever had a bad experience with sex? (forceful, non-­‐consensual, inappropriate or unwelcome touching) ☐ yes ☐ no Please describe to your level of comfort: ________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ Bladder Symptoms: Void frequency: ________ /day ☐ I have loss of urine with activities such as sneezing, running, jumping, lifting, laughing/coughing ☐ I have loss of urine that is preceded by a strong sensation that feels urgent with little warning ☐ I frequently have a strong sensation that feels urgent with little warning without loss of urine ☐ I have a high frequency of urination during the a) day: _______ #/day b) night: _______ #/night ☐ I have incontinence that results in frequent bed-­‐wetting ☐ I have incontinence that results in a need to wear pads ☐ I feel that I do not completely empty my bladder ☐ I feel I need to strain in order to urinate I have pain with: ☐ urination ☐ after urination ☐ full bladder ☐ I have difficulty initiating my urine stream Bowel Symptoms: Bowel Frequency: ________ /day ☐ I have fecal incontinence associated with the following activities: ____________________________________ ☐ I have a strong sensation for a bowel movement that feels urgent with little warning ☐ I feel frequently feel abdominal bloating I have pain with: ☐ bowel movement ☐ after bowel movement ☐ I feel I need to strain in order to successfully achieve ______% of my bowel movements in a week My stool consistency is: ☐ Loose ☐ Soft ☐ Lumpy/Hard ☐ Varies Pain: ☐ I have muscle or joint pain in my: ________________________________________________________________________ ☐ I have pain associated with my period: ☐ just before ☐ during days: ______ ☐ after period ☐ I have pain associated with my ovulation time (mid-­‐cycle) ☐ I have pain with tampon insertion or during sex ☐ I feel like something is going to fall out of my pelvis or feel a pressure/bulge in my pelvis On a scale from 0-­‐10, please rate your current pain (0=no pain, 10=worst imaginable) 0 1 2 3 4 5 6 7 8 9 10 * I feel my symptoms/pain interferes with my following life activities: ________________________________ _________________________________________________________________________________________________________________ Informed Consent for Pelvic Health Physiotherapy The Physiotherapy Act authorizes the activity of “putting an instrument, hand or finger beyond the labia majora or anal verge for the purpose of assessing or rehabilitating pelvic floor muscles relating to incontinence or pain disorders”. Conditions or issues that would benefit from Pelvic Health assessment and treatment include: • Urinary Incontinence • Urinary Retention • Pelvic Organ Prolapse • Vulvodynia or Vestibulodynia • Vaginismus or Dyspareunia • Interstitial Cystitis • Pregnancy-­‐related pelvic girdle pain • Chronic low back pain, hip pain or SIj pain Reasons for doing an internal examination: • Evaluate resting tone of pelvic floor muscles (normal vs. hypotonic vs. hypertonic) • Assess the strength, endurance, power, coordination and motor control of the pelvic floor muscles Potential risks of doing an internal examination: • Urinary tract infection • Pain • Spotting • Miscarriage with pregnancy I hereby consent to assessment and/or treatment given by registered physiotherapist Devonna Truong. I understand that my treatments may include treatments for therapeutic, preventative, diagnostic and/or other health related purposes. I understand that I may rescind my consent at any time. I understand that an internal assessment of the functioning of my pelvic floor may be deemed appropriate and there may be an internal component (vaginal/rectal) to the assessment and/or treatments. I have read the above consent and have had an opportunity to ask questions about its contents. _____________________________ _____________________________ _____________________________ Name (please print) Patient Signature Date (dd/mm/yy)