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Online Fillable Intake Form Pelvic Floor

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.

Uploaded by

Rakesh Kondaveeti
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
176 views2 pages

Online Fillable Intake Form Pelvic Floor

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.

Uploaded by

Rakesh Kondaveeti
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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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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