Pelvic Health Form - Oklahoma Physical Therapy

Name

Age

Date

1. Describe the problem that brought you here

2. When did your problem first begin

3. Was your first episode of the problem related to a specific incident/injury? Yes/No
—Please choose an option—YESNO

3. Please describe and specify date

4. Since that time/injury is it: ______ same ______ getting worse ______ getting better

Yes Same

Yes Getting Worse

Yes Getting Better

5. If pain is present, describe pain (ie. constant, burning, intermittent ache)

6. Describe any previous treatments/exercises

7. Check activities that may aggravate your symptoms (any/all that apply)

YesStanding Greater Than Minutes

YesWalking Greater Than Minutes

YesSitting Greater Than Minutes

YesWith Triggers

YesChanging Positions

YesLight Activity

YesVigorous Activity

YesWith Sexual Activity

YesWith Cough / Sneeze

YesWith Laughing / Yelling

YesWith Lifting / Bending

YesWith Cold Weather

YesWith Nervous / Anxiety

YesNo activity affects this

YesOther

Health History

(OB/GYN History) and (Bowel/Bladder Habits)

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 vaginal weights, 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.

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 and choose refuse this option.

Please use either your mouse, touchscreen, or digital pen to sign in the Signature Boxes below.