Download Pelvic Floor Questionnaire (doc)

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 )
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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
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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
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Social History
Alcohol use
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(type and frequency)
Tobacco use
Have you experienced:
Anxiety
Depression
Bipolar
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(type and ammount per day)
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Thoughts of wanting to harm
yourself or others?
Do you live alone?
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Do you have good emotional
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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)