Joint Physio Male Symptom Monitor

Male Symptom Monitor

*Pelvic floor assessments include an internal (rectal) exam.
Full Name
Birthdate

MonthDayYear
Date
Presenting Problems
When did this start?
Please fill out each section that is relevant to your problem

Have you had any of the following medical procedures? If so, please provide approximate date:
Appendectomy:

MonthDayYear
Date
Hernia Repair:

MonthDayYear
Date
Vasectomy:

MonthDayYear
Date
Hemorrhoid banding:

MonthDayYear
Date
Prostatectomy:

MonthDayYear
Date
Cystoscopy:

MonthDayYear
Date
Urodynamics:

MonthDayYear
Date
Gallbladder Removal:

MonthDayYear
Date
Bowel Resection:

MonthDayYear
Date
Colostomy:

MonthDayYear
Date
Other:

MonthDayYear
Date

Bladder Symptoms

Rows	Yes	No	Sometimes
Do you have leakage associated with sneezing, coughing, running and/or laughing?
Do you have leakage during intercourse?
Do you feel strong sensations prior to voiding but don’t leak?
Does your leakage occur after having a strong urge that feels uncontrollable?
Do you have pain when your bladder fills?
Does your pain improve when you void?
Do you have pain when you void?
Do you have to strain in order to empty your bladder?
Do you have difficulty starting your urine stream?
Do you have dribbling after you get up from the toilet?
Do you stand to void?
Do you have incomplete emptying when you void and feel like you have to go again soon?
Do your bladder problems cause you to leak at night?
Does your incontinence require you to wear pads?
Do you void during the day more than the average person (5-7x/day)?
Do you need to get up at night to void?

Digestion & Bowel Function

Rows	Never	Seldom	Always
Do you regularly feel the urge to move your bowels?
Do you have constipation?
Do you strain to have a bowel movement?
Do you have loose stools/diarrhea?
Do you have bowel urgency that is difficult to control?
Do you lose control of your bowels?
Do you have incomplete emptying?
Do you have pain with a bowel movement?
Do you have pain after a bowel movement?
Does it take longer than 5 minutes to have a bowel movement?
Do you have bloating? (increased pressure in abdomen)
Do you experience a physical change in abdominal girth when your bowels are full (distention)?

Medical History

Rows	Yes	No
Urinary tract infections?
Antibiotics recently?
Probiotics?
Cranberry supplementation?
Do you get blood in your urine?
Do you smoke?
Chronic cough?
Do you exercise?
Low back pain?
Mid back pain?
Neck problems?
Have you been treated for depression?
Is/was treatment effective?
Have you ever been treated for anxiety?
Is/was treatment effective?

Chronic?

Type a question

Rows	Yes	No
Does your prostate get painful or irritated?
Has your prostate fluid been expressed and tested?
Do you have painful erections?
Do you achieve a satisfactory erection?
Do you have premature ejaculation?
Do you have pain during intercourse?

Last digital rectal exam?
On a scale from 1-10, please check and rate how much this problem bothers you

12345678910
On a scale from 1-10, please circle and rate how motivated you are to correct this problem

12345678910
When? (Do you have pain during intercourse?)

DASS Questionnaire

Rows	0	1	2	3
S - I found it hard to wind down
A - I was aware of dryness of my mouth
D - I couldn't seem to experience any positive feeling at all
A - I experienced breathing difficulty (e.g., excessively rapid breathing, breathlessness in the absence of physical exertion)
D - I found it difficult to work up the initiative to do things
S - I tended to over-react to situations
A - I experienced trembling (e.g., in the hands)
S - I felt that I was using a lot of nervous energy
A - I was worried about situations in which I might panic and make a fool of myself
D - I felt that I had nothing to look forward to
S - I found myself getting agitated
S - I found it difficult to relax
D - I felt down-hearted and blue
S - I was intolerant of anything that kept me from getting on with what I was doing
A - I felt I was close to panic
D - I was unable to become enthusiastic about anything
D - I felt I wasn't worth much as a person
S - I felt that I was rather touchy
A - I was aware of the action of my heart in the absence of physical exertion (e.g., sense of heart rate increase, heart missing a beat)
A - I felt scared without any good reason
D - I felt that life was meaningless

Male Symptom Monitor