zenith_Pelvic_Health_Symptom

Symptom Monitor
Name
DOB

MonthDayYear
Date
Date

MonthDayYear
Date
Pronouns
Occupation
Presenting Problems
When did this start? Is there an event that you associate with the onset of your symptoms?
What do you think is causing your symptoms?
Are you?

MarriedWidowedSeparatedDivorcedPartnerSingle
Who lives in your home?
Who do you talk to about your issues?
This is a gender-neutral form – please fill out all applicable sections and/or questions so your therapist can better understand your symptoms
Have you had any of the following medical procedures/surgeries?

Bartholin CystBowel ResectionLaparoscopyCystoscopyColostomy/IleostomyHernia RepairAppendectomyCT/MRIProstatectomyRadiationChemotherapyUroliftVasectomyGallbladderHemorrhoid BandingMesh ProcedureProlapse/Vaginal RepairHysterectomyColonoscopyTVT-TOTX-Ray/UltrasoundTURPGreen Light LaserBrachytherapyHIFUUrodynamicsOther
Bartholin Cyst Date

MonthDayYear
Bowel Resection Date

MonthDayYear
Laparoscopy Date

MonthDayYear
Cystoscopy Date

MonthDayYear
Colostomy/Ileostomy Date

MonthDayYear
Hernia Repair Date

MonthDayYear
Appendectomy Date

MonthDayYear
CT/MRI Date

MonthDayYear
Prostatectomy Date

MonthDayYear
Radiation Date

MonthDayYear
Chemotherapy Date

MonthDayYear
Urolift Date

MonthDayYear
Vasectomy Date

MonthDayYear
Gallbladder Date

MonthDayYear
Hemorrhoid Banding Date

MonthDayYear
Mesh Procedure Date

MonthDayYear
Prolapse/Vaginal Repair Date

MonthDayYear
Hysterectomy Date

MonthDayYear
Colonoscopy Date

MonthDayYear
TVT-TOT Date

MonthDayYear
X-Ray/Ultrasound Date

MonthDayYear
TURP Date

MonthDayYear
Green Light Laser Date

MonthDayYear
Brachytherapy Date

MonthDayYear
HIFU Date

MonthDayYear
Urodynamics Date

MonthDayYear

Bladder Symptoms

Rows	Yes	No	Sometimes
Do you have leakage with coughing, sneezing, laughing?
Do you leak with exercising, running or jumping?
Do you have leakage during intercourse?
Do you feel a strong urge to void but do not leak?
Do you leak 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 while voiding?
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 urinate?
Do you sit on the toilet to void?
Do you feel fully empty after you void?
Do you lose bladder control during the night?
Does your incontinence fluctuate during your cycle?
Do you wear pads? Type?
Do you go to the bathroom more than 8 times per day?

How many pads do you use during the day?

12345+
How many times do you wake during the night to void?

012345+
What is the frequency of your bowel movements? E.g., 1x/per day

Do you go to the bathroom more than 8 times per day?

Rows	Yes	No	Sometimes
Do you regularly feel the urge to move your bowels?
Do you have constipation?
Do you strain to have a bowel movement?
Do you splint or assist to pass stool?
Do you use your finger to help evacuate stool?
Are you prone to having diarrhea/loose stool?
Do you have bowel urgency that is difficult to control?
Do you lose control of your bowels/accidental bowel leakage?
Do you have incomplete emptying after a bowel movement?
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 abdominal cramps/pain/?
Do you have bloating (increased pressure in abdomen)
Does your abdomen feel distended when your bowels are full?

In your opinion, is your fibre intake?

Too lowAdequateToo high
Do you regularly use?

LaxativesStool softenerNatural ProductsEnemas
Have your bowel habits changed recently including:

Unexplained Weight LossAbdominal PainRectal BleedingExcessive Straining

Have you ever been diagnosed with/think you have:

Rows	Yes	No
Irritable bowel syndrome
Ulcerative Colitis
Crohn’s Disease
Celiac Disease

At what age did you start your period?

Gynaecological History

Rows	Yes	No
Is your cycle regular?
Is your bleeding heavy?
Do you have any pain with your period? PMS? Cramps?
Do you use tampons or menstrual cups?
Do you have pain with insertion of a tampon or menstrual cup?
Do you have a lot of vaginal discharge?
Do you use birth control?
Are you sexually active?
Do you have pain with sexual activity?
Do you engage in penetrative intercourse?
Do you have pain with intercourse?
Do you have pain after intercourse
Do you have pain at the opening of vagina with sexual activity?
Do you have deep pain in the vagina with sexual activity?
Do you participate in anal sex?
Do you have pain with anal penetration?
Are you physically intimate with your partner without penetration?
Do you use lubrication with sexual activity?
Are you currently pregnant?
Are you currently breast/chest feeding
Have you had any miscarriages?
Did you have an epidural?
Did you have a vacuum-assisted delivery? Forceps delivery?
Did you have episiotomies? Tearing? Grade?
Did you feel supported and cared for during labour?
Were there times during labour and delivery that you felt in danger?
Do you suffer/have you suffered from post-partum depression/anxiety?
Have you gone through menopause?
Do you suffer from vaginal dryness?
Are you on any Hormone Replacement Therapy?
Do you use a vaginal moisturizer such Replens/Gynatrof/Repagyn?
Do you have feelings of heaviness/pressure in your vagina?
Do you physically feel something coming out of your vagina?
Have you ever been told you have a prolapse?
Do you have sensory changes/loss in your genitals?
Do you have a history of vulvar varicosities?

How many days does your period last?

12345+
# Of pregnancies?

1234+
# Of C-sections?

1234+
# Of vaginal deliveries?

1234+
Weight of heaviest baby?
Age of child(ren)?
How long did you push during labour?

1234+ (hrs)
When was your last PSA test?
When was your last digital rectal exam?

Prostate/Penile History

Rows	Yes	No
Does your prostate get painful/irritated?
Has your prostate fluid been expressed and tested?
Do you have painful erections? Pain with ejaculation?
Can you achieve a satisfactory erection?
Do you experience nocturnal erections?
Do you have premature ejaculation?
Do you participate in anal sex?
Do you have pain with anal penetration?
Are you physically intimate with your partner without penetration?
Do you have sensory changes/loss in your genitals?

Fluid intake in a 24-hour period (approximately)
Number of cups of water per day
Number of cups of other fluids/day (milk, juice, broth, soup)
Number of cups of coffee/day
Number of alcoholic drinks/day
Number of cups of tea/day
Number of carbonated drinks/day (pop, seltzer, carbonated water)
Number of energy drinks/day
Other
Number of Other/day
Do you have any allergies (gel/vinyl) or food sensitivities/allergies?

Medical History

Rows	Yes	No
Urinary Tract Infections
Recent antibiotics?
Do you use probiotics?
Do you use cranberry supplements?
Do you smoke? Amount?
Do you have a chronic cough?
Do you get yeast infections?
Do you get blood in your urine?
Allergies?
Do you exercise?
Low back problems?
Mid back problems?
Neck problems?
Depression?
Anxiety?
Have you been diagnosed with a mental health condition?

Urinary Tract Infections Notes
Recent antibiotics? Notes
Do you use probiotics? Notes
Do you use cranberry supplements? Notes
Do you smoke? Amount? Notes
Do you have a chronic cough? Notes
Do you get yeast infections? Notes
Do you get blood in your urine? Notes
What kind of allergies?
What type of exercise?
Low back problems? Notes
Mid back problems? Notes
Neck problems? Notes
Depression? Notes
Anxiety? Notes
Have you been diagnosed with a mental health condition? Notes
What physicians or health care providers have you seen for these problems?
Physician/provider #1
Treatment provided #1
Physician/provider #2
Treatment provided #2
Physician/provider #3
Treatment provided #3
Please list the medications you are currently taking (including vitamins and supplements)
Medication/dose #1
Provider #1
Medication/dose #2
Provider #2
Medication/dose #3
Provider #3
Medication/dose #4
Provider #4
Medication/dose #5
Provider #5
Medication/dose #6
Provider #6

Currently taking?

Rows	Yes	No	Currently taking
Medication/dose #1
Medication/dose #2
Medication/dose #3
Medication/dose #4
Medication/dose #5
Medication/dose #6

Is there anything else you would like to mention that might be important or relevant?
On a scale from 1-10, please select and rate how much this problem bothers you?

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

12345678910
Insomnia Severity Index

The Insomnia Severity Index has seven questions. The seven answers are added up to get a total score. When you have your total score, look at the 'Guidelines for Scoring/Interpretation' below to see where your sleep difficulty fits.

For each question, please CIRCLE the number that best describes your answer.

Please rate the CURRENT (i.e. LAST 2 WEEKS) SEVERITY of your insomnia problem(s).

Insomnia Problem

Rows	None	Mild	Moderate	Severe	Very Severe
1. Difficulty falling asleep
2. Difficulty staying asleep
3. Problems waking up too early

4. How SATISFIED/DISSATISFIED are you with your CURRENT sleep pattern?

Very SatisfiedSatisfiedModerately SatisifiedDissatisfiedVery Dissatisfied
5. How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life?

Not at all NoticeableA littleSomewhatMuchVery Much Noticeable
6. How WORRIED/DISTRESSED are you about your current sleep problem?

Not at all WorriedA littleSomewhatMuchVery Much Worried
7. To what extent do you consider your sleep problem to INTERFERE with your daily functioning (e.g. daytime fatigue, mood, ability to function at work/daily chores, concentration, memory, mood, etc.) CURRENTLY?

Not at all InterferingA littleSomewhatMuchVery Much Interfering
DASS Questionnaire

Please read each statement and circle a number, o, 1, 2, or 3, which 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.
S
A
D
0 = It did not apply to me at all
1 = Applied to me to some degree orsome of the time
2 = Applied to me a considerable degree, or a good part of the time
3 = Applied to me very much, or most of the time

DASS Questionnaire

Rows	0	1	2	3
S - I find it hard to wind down
A - I was aware of dryness of my mouth
D- I could not seem to experience any feeling at all
A- 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. 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 was not much of 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

Should be Empty:

Symptom Monitor

Fluid intake in a 24-hour period (approximately)

What physicians or health care providers have you seen for these problems?

Please list the medications you are currently taking (including vitamins and supplements)

Insomnia Severity Index

DASS Questionnaire