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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
PELVIC FLOOR QUESTIONNAIRE Name____________________________________________ Age: _________ Weight: _________ Occupation_______________________________Employer________________________________Hours worked per week__________ What are your symptoms? ___________________________________________________________________________________ When did symptoms start? (Onset Date) ___________Surgery Date ___________Where did you have surgery? ____________ Cause of symptoms? _________________________________________________________________________________________ Since onset, your symptoms are: Worse Same Better Prior to this onset, were you symptom free? Yes No What increases your symptoms? _______________________________________________________________________________ What decreases your symptoms? _______________________________________________________________________________ (Worst pain Please rate your current pain (circle): (No pain) 0 (Moderate) 1 2 3 4 5 imaginable) 6 7 8 9 10 Daily Activities: Home/Leisure Limitations__________________________________________________________________ Self-Care Limitations______________________________________________________________________ Do you exercise? _______ How often? _______________ Type ___________________________________ Do you have any allergies? _________________________________________________________________________________ Medical History: Ob/Gyn History (Females Only) Yes Yes Yes Yes Yes Yes No No No No No No Births: vaginal # ____ c-section #____ Difficult childbirth Vaginal dryness Pregnant or attempting pregnancy Prolapse/Rectocele/Cystocele Painful Menstruation Yes Yes Yes Yes Yes No No No No No Menopause - When? Pelvic/genital pain Hysterectomy IUD in place Endometriosis Prostate disorders Shy bladder Pelvic/genital pain Yes Yes Yes No No No Erectile Dysfunction Painful Ejaculation Hernia – Where? Yes Yes Yes Yes Yes Yes No No No No No No Dribbling after urination Constant urine leakage Trouble feeling bladder urge/fullness Recurrent bladder infections Painful urination Volume passed __small __med __large Comments: Males Only Yes Yes Yes No No No Comments: Bladder Symptoms Yes Yes Yes Yes Yes Yes No No No No No No Comments: Trouble initiating urine stream Urine intermittent/slow stream Strain or push to empty bladder Need to urinate with little warning Trouble emptying bladder completely Blood in urine Urinary Habits Frequency of urination: Every ____minutes; Every ____ hours; On average, how much do you leak? None Just a few drops ____times per day; ____times per night Wet underwear Wet the floor Soaked pads Can you delay before you go to toilet? _____ minutes (# of minutes) _____hours (# of hours) Not at all Bladder leakage: # of episodes: None without awareness with exertion/cough with urge ____times/day; ____times/week; ____times/month What form of protection do you wear? None Minimal protection (toilet paper/pantishield) Moderate protection (absorbent product/maxipad) Maximum protection (specialty product/diaper) On average, how many pad changes are required during daytime? _____(#of pads) at night?____(#of pads) Are they damp____ wet _____ soaked_____ Average fluid intake (1glass = 8 oz) ____# glasses/day Of this total how many glasses are: Caffeinated? ____# glasses/day Fruit drinks? ____# glasses/day Alcoholic? ____# glasses/day Water? ____# glasses/day Comments: Bowel History Yes Yes Yes Yes Yes No No No No No Blood in bowel movement (BM) Painful BM Trouble feeling bowel urge Trouble holding back gas Trouble starting BM Yes Yes Yes Yes Yes No No No No No Trouble emptying bowel completely Need to support/splint to complete BM Constipation/straining ____% of time Current laxative use Fecal leakage ___times/day ___times/week Comments: Bowel Symptoms Frequency of bowel movements: ____times/day; ____times/week When you have the urge to have a bowel movement, how long can you delay? Minutes Hours Not at all Bowel movements are typically: Watery Loose If constipation is present, describe management techniques: Formed Pellets Thin Hard Comments: Rate a feeling of organ ”falling out”/prolapse or pelvic heaviness/pressure None present With exertion or straining Pressure at end of the day Comments: With standing for ____minutes or ____hours With menses Pressure all day Sexual History Yes No Yes No If Yes, Sexually active Pain with penetration Yes No with tampon (females) Yes No with speculum(females) Yes No Pain w/erection(males) Yes No Pain w/ejaculation (males) Yes Yes Yes Yes No No No No Pain with initial entry Pain with deep thrust Bleeding with or following intercourse History of sexual abuse Comments: Activities that cause or aggravate any of your bladder/bowel symptoms or pain (check all that apply) Sitting greater than ____minutes Walking greater than ____minutes Standing greater than ____minutes Changing positions (sit to stand) Light activity (light housework) Vigorous activity/exercise (run, weight lift, jump) Sexual activity Cough/sneeze/straining Comments: Laughing/yelling Lifting/bending Cold weather Triggers (key in the door/running the water) Nervousness/anxiety Sleeping No activity affects the problem Please list your goals. (What do you want this treatment to do for you?) __________________________________________________ ____________________________________________________________________________________________________________ Please list your current medications: Patient History Form Patient Name Date Medical History High Blood Pressure Heart Attack Congestive heart failure Pacemaker Raynauds Asthma COPD Stroke Vertigo/Dizziness Seizures Migraines Thyroid Disease Diabetes Kidney Disease Herpes Shingles IBS Psoriasis Eczema Open sores Rash Cancer (specify right ) ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ Fracture Rheumatoid arthritis Osteoarthritis Gout Neuropathy Parkinsons Alzeheimers MS Fibromyalgia HIV Osteoperosis Liver Disease Hepatitis Reflux Leukemia Bleeding Disorder Constipation Diarrhea Interstitial Cystitis Prostate problems ⃝ Auto-Immune Disease Have you had any serious illness not listed above? No ⃝ Do you bruise easily? Yes ⃝ Yes No ⃝ Surgeries Noteable family medical history? Turn Over ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ Social History Alcohol use ⃝ ⃝ (type and frequency) Tobacco use Have you experienced: Anxiety Depression Bipolar ⃝ ⃝ (type and ammount per day) ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ Thoughts of wanting to harm yourself or others? Do you live alone? ⃝ ⃝ Do you have good emotional ⃝ ⃝ support? Always ⃝ Sometimes ⃝ Never ⃝ Do you use a seat belt? Diet? (Please Rate) Good ⃝ Fair ⃝ Poor ⃝ Any other current life event that may impact therapy? (moving, baby, family death, job change, etc)