Pelvic Floor Medical History Name: ______________________________________ (Last, First) DOB: ________________________________________

Date: ____________________ Age: _____________________

Referring Physician: Next Physician Appointment:

Today’s visit: What is the main reason you came to the office today?

When did it start? What treatments have you had so far for this health issue?

Medical History:

Please list any and all current medical conditions you may have: 1. ________________________________________ 2. _________________________________________ 3. ________________________________________ 4. _________________________________________ 5. ________________________________________ 6. _________________________________________ 7. ________________________________________ 8. _________________________________________ 9. _______________________________________ 10._________________________________________ Please list or attach a list of your current medications and how often you take them—including birth control, hormone replacement medications, vitamins, and herbal supplements. Medication Dose Frequency (Schedule) 1. ___________________________________________________________________________________________ 2. ___________________________________________________________________________________________ 3. ___________________________________________________________________________________________ 4. ___________________________________________________________________________________________ 5. ___________________________________________________________________________________________ 6. ___________________________________________________________________________________________ 7. ___________________________________________________________________________________________

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Please list any past surgeries and dates: 1. ___________________________________________ 2. ___________________________________________ 3. ___________________________________________ 4. ___________________________________________ 5. ___________________________________________ 6. ___________________________________________ Please list any allergies and your reactions to them: Allergy Reaction 1. ___________________________________________________________________________________________ 2. ___________________________________________________________________________________________ 3. ___________________________________________________________________________________________

Past Obstetrical History (if applicable): How many times have you been pregnant: Of these pregnancies, how many were… Preterm (premature) deliveries Full term deliveries Miscarriages or abortions Cesarean delivery Forceps or vacuum Weight of largest baby:

______ ______ ______ ______ ______ ______

Past Gynecological History: Are you sexually active?

Yes

No

If No, why not? ____________________

Please circle any of the follow that you currently have. Heavy menstruation Fibroids (Myomas) Irregular bleeding Sexually transmitted infections (gonorrhea, chlamydia, herpes) Abnormal pap smear Pelvic infection (PID) Ovarian cysts or tumors Other: ______________________________________

Social History: Are you? (Circle one):

Single Divorced

Who do you live with? Do you currently work? Yes No Do you exercise? Yes No Describe your current exercise routine:

Married Widowed

Domestic Partner Other:_____________________________

What is your current/most recent job?

Do you smoke? Yes No If yes, how many per day? 5 10 20 20+ Do you drink alcohol? Yes No If yes, how much per week? ______________________________ Do you use any other drugs? Yes No If yes, please list: During the past month, have you been bothered by feeling down, depressed or hopeless? Yes No Have you ever been emotionally, physically, or sexually abused? Yes No If yes, by whom: ________________________________________________________ When? ________________

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Urological History: How many times do you urinate during the day? ____ How many times do you urinate during the night after you go How much liquid do you drink per day? _____________ to sleep? ___________ Does the urge to urinate wake you up? Yes No After emptying your bladder do you have the feeling Do you find it difficult to begin urinating? Yes No that you have not finished? Yes No Do you experience leakage of urine? Yes No Do you leak urine when you cough, sneeze or laugh? Yes No If yes, how long: _______ Month (s) _______ Years After you urinate, do you have dribbling? Yes No Do you leak urine with urgency or on the way to the bathroom? Yes No Please CIRCLE if you leak urine during the following situations: Walking Running Urgency Changing from sitting to standing Lying Down Exercise Minimal Activity With Intercourse Straining/lifting Do you use a pad for urine leakage? Yes No When was your last episode of urine leakage? If yes, how many per day? _________________ Do you ever wet the bed while sleeping? Yes No What amount of leakage do you experience? (Circle) Drops More than drops Flood Leak continually Do you have sensation or awareness when you experience leakage of urine? Yes No

How long can you postpone emptying your bladder when you have the urge to urinate? _________minutes _________hours

Bowel Symptoms: How often do you have a bowel movement? Do you strain with a bowel movement?

Do you push with a finger in the vagina to assist with a bowel movement?

Please CIRCLE the bowel symptoms you are experiencing: Diarrhea Constipation Incontinence Laxative Use Increased Fiber Use Stool softener Use Difficulty controlling formed stools: Fecal soiling Yes No Liquid stools Yes No Flatus gas Yes No Additional Comments:

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Health Review of Systems: GENERAL Yes No Yes No Yes No Yes No Yes No

Excessive fatigue Weight loss Excessive thirst Feeling abnormally hot or cold Lumps or swelling

SKIN Yes Yes Yes Yes Yes

No No No No No

NERVOUS SYSTEM Yes No Frequent or severe headaches Yes No Recurrent numbness or tingling of hands/feet Yes No Mood swings, irritability

HEART Yes No Yes No Yes

No

Yes Yes Yes

Yes Yes Yes

No No No

No No No

Depression or anxiety Dizziness Fainting

Rashes Recurrent sores Moles that have changed in color / size Swollen glands Itching Chest pain Heart palpitations (irregular heartbeats) Discomfort in the chest with exercise or walking Difficulty breathing High blood Pressure Anemia

EAR, NOSE, THROAT Yes No Hearing difficulty Yes No Ringing in the ear Yes No Changes in vision Yes No Change in voice Yes No Difficulty swallowing

LUNGS Yes No Yes No Yes No Yes No Yes No

Shortness of breath Cough Wheezing Coughing up blood Difficulty breathing

GASTROINTESTINAL Yes No Constipation Yes No Diarrhea Yes No Heartburn Yes No Frequent nausea and/or vomiting Yes No Poor appetite Yes No Blood in stool

URINARY Yes No Yes No Yes No Yes No Yes No

Urine leakage Pain with urination Excessive urinating at night Bladder infections Kidney stones

GYNECOLOGICAL Yes No Pelvic pain Yes No Pain with sex Yes No Pain after sex Yes No Bleeding after sex Yes No Sores or ulcers Yes No Severe cramps with period Yes No Irregular bleeding/ Bleeding between periods Yes No Heavy bleeding

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Consent for Evaluation and Treatment of the Pelvic Floor 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 (SI) 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 physical therapist perform an internal manual 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 internally and/or externally. Such evaluation may include vaginal or rectal sensor for muscle biofeedback. Treatment may include, but not be limited to, the following: observation, palpation, and the use of vaginal weights, vaginal or rectal sensors for biofeedback and/or electrical stimulation, ultrasounds, 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 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 physical therapist. 1. The purpose, risks, and benefits of this evaluation have been explained to me. 2. I understand that I can terminate the procedure at any time. 3. I understand that I am responsible for immediately telling the examiner if I am having any discomfort or unusual symptoms during the evaluation. 4. I have the option of having a second person present in the room during the procedure. I would like to request to have an additional person present during the examination_______

_______________________________________________ Patient Name

_____________________________________________ Date

_______________________________________________ Patient Signature

_____________________________________________ Parent/Guardian Signature (if applicable)

________________________________________________ Therapist Signature Page 5 of 5