Pelvic Floor Therapy Questionnaire

Patient Name

Date

Please fill in the following questionnaire to the best of your ability. The therapist will review the answers with you at your appointment.

History

Number of pregnancies

Number of vaginal deliveries

Birth weight of largest baby

Number of cesarean deliveries

Number of episiotomies

Date of last pap smear

Did you have any trouble healing after delivery

Yes No

Do you have a history of sexual abuse or trauma

Yes No

Are you having regular periods/ menstrual cycles

Yes No

Do you have frequent urinary tract infections

Yes No

Pain

Do you have pain with:

Sexual intercourse

Yes No

Pelvic exam

Yes No

Tampon use

Yes No

Back, leg, groin, abdominal pain

Yes No

Test results

Urodynamics test

Yes No

Short text

Cystoscope

Yes No

Short text

Urine Test

Yes No

Short text

Bowel Test

Yes No

Short text

Bladder symptoms

Do you lose urine when you:

Cough/sneeze/ laugh

Yes No

On the way to the bathroom

Yes No

Hear running water

Yes No

Do you wet the bed

Yes No

Have burning/ pain with urination

Yes No

Difficulty starting a stream of urine

Yes No

Strain to empty your bladder

Yes No

Feel unable to empty bladder fully

Yes No

Have a falling out feeling

Yes No

Have an urgency of urination (a strong urge to urinate)

Yes No

Urinate more than 7 times/day

Yes No

Lift/ exercise/ dance/ jump

Yes No

Have a strong urge to urinate

Yes No

Other

Yes No

Please specify.

Bowel symptoms

Strain to have a bowel movement

Yes No

Include fiber in your diet

Yes No

Take laxatives/ enema regularly

Yes No

Have pain with bowel movement

Yes No

Have a very strong urge to move your bowels

Yes No

How often do you move your bowels:

Most common stool consistency

liquid

soft

firm

pellets

other

If other, please specify.

Leak/ stain feces

Yes No

Have diarrhea often

Yes No

Leak gas by accident

Yes No

Thank you for taking the time to fill out this questionnaire.

PELVIC FLOOR CONSENT FOR EVALUATION AND TREATMENT

I acknowledge and understand that I have been referred for evaluation and treatment of pelvic floor dysfunction. Pelvic floor dysfunctions include, but are not limited to, urinary or fecal incontinence; difficulty with bowel, bladder, or sexual functions; painful scars after childbirth or surgery; persistent sacroiliac or low back pain; or pelvic pain conditions.

I understand that to evaluate my condition it may be necessary, initially and periodically, to have my therapist perform an internal pelvic floor muscle examination. This examination is performed by observing and/ or palpating the perineal region including the vagina and/or rectum. This evaluation will assess skin condition, reflexes, muscle tone, length, strength and endurance, scar mobility, and function of the pelvic floor region. Such evaluation may include vaginal or rectal sensors for muscle biofeedback.

Treatment may include, but not be limited to, the following: observation, palpation, use of perineal sensors, vaginal or rectal sensors for biofeedback and/ or electrical stimulation, ultrasound, heat, cold, stretching and strengthening exercises, soft tissue and/ or joint mobilization, and educational instruction

I understand that in order for therapy to be effective, I must come as scheduled unless there are unusual circumstances that prevent me from attending therapy. I agree to cooperate with and carry out the home program assigned to me. If I have difficulty with any part of my treatment program, I will discuss it with my therapist.

The purpose, risks, and benefits of this evaluation will be explained to me.
I understand that I can terminate the procedure at any time.
I understand that I am responsible for immediately telling the examiner if I am having any discomfort or unusual symptoms during the evaluation.
I have the option of having a second person present in the room during the procedure and

choose OR refuse this option

Date

Patient Name

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature

Signature of Parent or Guardian (if applicable)

Witness Signature

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