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    Online Fillable Intake Form Pelvic Floor

    Uploaded by

    Rakesh Kondaveeti
    The pelvic floor medical history form collects information about a patient's main health concerns, symptoms, treatments tried, general health, medical history including surgeries and testing, medications, lifestyle factors like smoking, exercise and stress levels, work and home activities, pain levels and triggers, incontinence, bowel movements, and sexual history. The form aims to provide physicians an overview of the patient's medical background and goals for pelvic floor physiotherapy treatment.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Online Fillable Intake Form Pelvic Floor

    Uploaded by

    Rakesh Kondaveeti
    44 views2 pages
    The pelvic floor medical history form collects information about a patient's main health concerns, symptoms, treatments tried, general health, medical history including surgeries and testing, medications, lifestyle factors like smoking, exercise and stress levels, work and home activities, pain levels and triggers, incontinence, bowel movements, and sexual history. The form aims to provide physicians an overview of the patient's medical background and goals for pelvic floor physiotherapy treatment.

    Original Description:

    Pelvic floor form

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    The pelvic floor medical history form collects information about a patient's main health concerns, symptoms, treatments tried, general health, medical history including surgeries and testing, medications, lifestyle factors like smoking, exercise and stress levels, work and home activities, pain levels and triggers, incontinence, bowel movements, and sexual history. The form aims to provide physicians an overview of the patient's medical background and goals for pelvic floor physiotherapy treatment.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    44 views2 pages

    Online Fillable Intake Form Pelvic Floor

    Uploaded by

    Rakesh Kondaveeti
    The pelvic floor medical history form collects information about a patient's main health concerns, symptoms, treatments tried, general health, medical history including surgeries and testing, medications, lifestyle factors like smoking, exercise and stress levels, work and home activities, pain levels and triggers, incontinence, bowel movements, and sexual history. The form aims to provide physicians an overview of the patient's medical background and goals for pelvic floor physiotherapy treatment.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    Pelvic Floor Medical History Form

    Name Age

    What are your main concerns? How would you rate your general health?
    1)

    2)
    Do you have any other health concerns?

    3)

    List pelvic/abdominal surgeries and dates.


    When did your symptoms begin?

    List any testing or screening and dates.


    How did your injury occur?

    Please list any medication and it’s purpose.


    How have your symptoms affected your life?

    What treatment have you tried before?


    Do you smoke?
    (including health professionals you have
    worked with)

    What do you do for exercise outside of normal


    activities?

    What is your stress level? How do you


    What is your main goal with pelvic physio manage stress?
    treatment?
    Work Pain
    Occupation, and activities at work (sitting, lifting)
    Do you experience pain?

    Home How would you describe your pain?

    Who lives with you at home?

    Are you pregnant?

    What aggravates your symptoms?

    # of Vaginal deliveries

    # of Caesarean deliveries

    Incontinence
    Do you experience leakage:

    daily weekly monthly

    What relieves your symptoms?

    Severity of leakage

    Few drops wet underwear

    Wet outerwear

    When do you experience leakage?

    Sexual History
    Are you sexually active? Yes No

    Do you have any pain or concerns with sexual


    activity? Yes No

    How often do you empty your bladder?

    Can you delay the need to empty your bladder?

    Other - Is there anything you would like to let


    me know?
    Bowel Movements
    Times per week

    Do you have any vaginal or rectal heaviness/


    pressure?

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