Joint Physio Female Symptom Monitor

Female Symptom Monitor

*Pelvic floor assessments include an internal (vaginal and/or rectal) exam.
Full Name
Birthdate

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

Gynecological History

Rows	Yes	No
Is your cycle regular?
Do you suffer from PMS?
Is your bleeding heavy?
Do you have pain with your period?
Do you use tampons?
Do you have pain with insertion of a tampon?
Do you have excessive discharge?
Sexually active?
Do you use birth control?
Pain with intercourse?
Did you have an epidural?
Did you have a vacuum-assisted delivery?
Were forceps used?
Did you have an episiotomy?
Tears?
Were there times during labour and delivery that you were (or thought you were) in danger of death or injury?
Were there times when the baby was or seemed to be in danger during labour and delivery?
Did you suffer/have you suffered from post-partum depression?
Have you gone through menopause?
Do you suffer from vaginal dryness?
Hormone replacement therapy?
Do you use lubrication?
Do you have feelings of heaviness/pressure in your vagina?
Have you ever been told you have a prolapse?

At what age did your period start?
How long is your cycle?
If yes, when?
Type?
Number of pregnancies?
Number of live births?
Heaviest baby: lbs
Heaviest baby: oz.
Length of pushing stage: # of hours
Number of C-sections?
Number of vaginal deliveries?
During my labour(s) and delivery, I felt supported and cared for:

All or most of the timeSome of the timeA little bitNot at all
Have you gone through menopause: If so, when?
Hormone replacement therapy: If yes, what?
Use lubrication: What type?
Told you have a prolapse: What type?
Have you had any of the following medical procedures? If so, please provide approximate date:
Appendectomy:

MonthDayYear
Date
Bartholin Cyst:

MonthDayYear
Date
Bowel Resection:

MonthDayYear
Date
Laparoscopy:

MonthDayYear
Date
Cystoscopy:

MonthDayYear
Date
Colostomy:

MonthDayYear
Date
TVT-TVT(O):

MonthDayYear
Date
Gallbladder Removal:

MonthDayYear
Date
Hemorrhoid Surgery:

MonthDayYear
Date
Mesh Procedure:

MonthDayYear
Date
Prolapse/Vaginal Repair:

MonthDayYear
Date
Hysterectomy:

MonthDayYear
Date
Other:

MonthDayYear
Date

Bladder Symptoms

Rows	Yes	No	Sometimes
Did you have problems with your bladder during childhood?
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 sit on the toilet?
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 fluctuate with your cycle?
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?

Does your incontinence require you to wear pads? If you answered yes or sometimes, how often?
Do you void during the day more than the average person (5-7x/day)? If you answered yes or sometimes, how often?
Fluid Intake in 24 Hours
Do you need to get up at night to void? If you answered yes or sometimes, how often?
# of cups of water/day
# of cups of coffee/day
# of tea/day
# of cups of other fluids/day
# of alcoholic drinks/day
What is the frequency of your bowel movements

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?
Yeast Infections?
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?

Exercise: Type & Frequency:
On a scale from 1-10, please circle 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
DASS Questionnaire

Please read each statement and circle a number 0, 1, 2 or 3 that indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

0 = Did not apply to me at all
1 = Applied to me to some degree, or some of the time
2 = Applied to me to a considerable degree, or a good part of time
3 = Applied to me very much, or most of the time

DASS Questionnaire

Rows	Not Satisfied	Somewhat Satisfied	Satisfied	Very Satisfied
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

Female Symptom Monitor