longlake_Pelvic_Health

Name

Date

Please explain the main reason for your visit

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Do you have any medical conditions diagnosed by a medical professional? Please list them

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Please list any previous injuries and surgeries and the date

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Please list any medications you are currently on

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Have you seen anyone else for these symptoms

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Please check any boxes that apply to you. If you do check the box, please elaborate on these symptoms.

Rows	Yes	Elaborate
Pain at night, or night sweats
Medical history of cancer diagnosis
Unexplained weight loss
Loss of sensation in perineal region (where you wipe yourself on the toilet)
Uncontrolled bladder and bowel leakage, with no sensation of needing to go to the bathroom
Signs of infection including fever, redness, swelling, discharge from skin/wound
Currently smoking or previously smoked cigarettes

Please fill out this section if you are currently pregnant. In this pregnancy do you have:

Rows	Yes
Mild, moderate or severe respiratory or cardiovascular disease?
Epilepsy that is not stable
Type 1 Diabetes that is not stable or blood sugar outside of your target ranges?
Thyroid disease that is not stable or thyroid function out of target ranges?
An eating disorder or malnutrition?
Twins (28 weeks pregnant or later?) OR expecting triplets or higher multiple births?
Anemia with high levels of fatigue or light headed ness?
High blood pressure (preeclampsia, gestational hypertension, or chronic hypertension)?
A baby that is growing slowly (intrauterine growth restriction)?
Unexplained bleeding, ruptured membrane or labour before 37 weeks?
Placenta previa?
Incompetent cervix?
A stitch or tape to reinforce your cervix (cerciage)?
In previous pregnancies recurring miscarriages (loss of baby <20 weeks), early delivery (<37 weeks)

If you selected twins or expecting triplets or higher multiple births, please specify

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If you selected high blood pressure (preeclampsia, gestational hypertension, or chronic hypertension) please specify

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If you selected a baby that is growing slowly, please specify

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If you selected recurring miscarriages, please specify

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Please check the box that applies to you.

Rows	Yes	Elaborate
I am currently pregnant. (No need to elaborate)
I have been told I have a high-risk pregnancy. (No need to elaborate)
I have been pregnant in the past. If you check yes, please explain the type of delivery, birth weight of baby/babies, occurrence of episiotomy or tearing, and any complications that occurred.
I have a history of recurring UTI's and yeast infections. If you check yes, please tell us the date of the last infection.
I am on an IUD or birth control. If you check yes, please state what kind.
I am currently on Hormone Replacement Therapy. If you check yes, please tell us what kind and for how long
I have been diagnosed with a prolapse in the past. If you check yes, please explain the type, degree, and who diagnosed you.

Please explain your menstrual cycles in the past (heaviness, pain 0-10, did you have to take time off work? Any irregularity?

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Please check the box for any procedures you have had done. If you do, please list the date or year of the procedure.

Please check the box that applies to you, and expand in the notes where applicable.

Rows	Yes	Expand
I leak urine when I cough or sneeze.
I leak urine with intercourse
I have a strong sensation to void but don't leak
I have leakage after a strong urge
I have pain when my bladder fills
I have pain when urinating
I have to strain to empty my bladder
I have difficulty starting my urine stream
I dribble after getting up from the toilet
It feels like I do not fully empty my bladder or I have to go pee right after I have just gone
I leak urine at night
I wake up at night to pee
I wear pads or liners
I go to the bathroom more than 8 times in 24 hours

Please list how much fluid you drink in a day and what type of fluid it is (e.g Coffee - 2 cups)

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Please check the box that applies to you. Elaborate in the note beside if you want to add more information.

Rows	Yes	Elaborate
I have pain with a bowel movement
I have urgency with bowel movements that is difficult to control
I feel constipated
I have diarrhea or loose stools
I have bowel leakage
I do not fully empty my bowels on the toilet
I have pain with bowel movements
I have pain after a bowel movement
I have blood in my stool
I have to use laxatives, enemas, or stool softeners
I have been diagnosed with IBS, ulcerative colitis, crowns, and/or celiac disease

Please explain how often you have a bowel movement, and if this is normal for you

0/50

Finally, on a scale of 0-10, 0 being not bothersome at all, how much does this problem bother you?

0/50

Pelvic Floor Physio Therapy Intake Form