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Pelvic Rehabilitation Patient Form

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Pelvic Rehabilitation Patient Form

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Pelvic Rehabilitation Patient Form

Please fill out the outpatient rehabilitation health questionnaire below before your appointment. Appointments are by referral only. Please call 401-793-2145 for additional information.

Personal Information

First Name

Last Name

Date of Birth

Gender Identity

Sex assigned at birth

Pronouns

Describe Your Problem

Describe the problem for which you seek therapy:

When did the problem begin?

What are your goals for therapy?

Pain

Do you have pain?

Yes

Where is the location of the pain?

Please describe this pain:

Please rate your pain (0=no pain, 10=worst pain imaginable) over the past 24 hours:

At best:

At worst:

Presently:

What activities or movements make it better?

What activities or movements make it worse?

Current and Recent Issues

Due to current symptoms/surgery/injury, I am having problems with:

Have you RECENTLY had any of the following problems?

Bowel/Bladder Problems

Dizziness/Blackouts

Depression/Anxiety

Nausea/Vomiting

Urinary Problems

Non-healing Wound

Chest Pain

Loss of Balance/Falling

Fever/Chills/Sweats

Numbness/Tingling

Weakness in Legs/Arms

Weight Loss/Gain

Shortness of Breath/Cough

Swollen Hands, Feet, Ankles, Legs

Heart Palpitations

Pain/Cramping in Calf

Tremors/Shaking

Menstrual Problems

Trauma

Abuse

Repeated Infections

Unusual Lumps/Growths

Sexually Transmitted Infection

Other

If "Other," please describe:

Medical History

Have you been diagnosed with:

Arthritis

Circulatory/Vascular Problems

Heart Disease

Kidney or Liver Problems

Infectious Disease (HIV, Hepatitis)

Osteoporosis or Osteopenia

Heart Problems

Depression or Anxiety

Head Injury

Low Blood Pressure

Lung Problems

Seizure Disorder or Epilepsy

Broken Bones/Fractures

Diabetes

High Blood Pressure

Neurological Problems

OB/GYN Problems

Thyroid Problems

Cancer

Fibromyalgia

Incontinence

Hearing Loss

Psychiatric Disorders

Visual Impairment

Other Medical Condition(s)

If "Other," please describe:

Surgical History

Have you ever had surgery?

Please list the type of surgery.

Date of surgery:

Please provide details and date(s) of your surgical history:

Tests

Within the past year have you had any diagnostic tests (X-ray, MRI, Anorectal manometry, urodynamics study)?

Please list the type of test(s).

Allergies

Do you have any allergies?

Yes--I have allergies.

No--None that I am aware of.

Please list your allergy/allergies:

OB/GYN History

Check all that apply:

Complicated pregnancies or deliveries

Prolapse

Endometriosis

Other gynecological or obstetrical difficulties

Pelvic Inflammatory Disease

Trouble with your period

Vaginal dryness

Postpartum depression

How many complicated pregnancies or deliveries? Please describe:

Have you ever had ob/gyn surgery?

Check all that apply:

Tubal Ligation

Laparoscopy

Abdominal Hysterectomy

Vaginal Hysterectomy

Gall Bladder

Bladder Surgery

Pelvic Surgery

Vaginal Surgery/Laser

Vulvar Surgery

Pudendal Nerve Surgery

Other

If "Other," please describe:

Have you experienced menopause?

Approximately when did menopause end for you?

If "Other," please describe:

Are You Pregnant?

When is your due date?

History of Previous Pregnancies

Have you been pregnant in the past?

Yes

Number of total pregnancies:

Number of live births:

Number of childbirth vaginal deliveries:

Have you had a prolonged second stage labor?

Number of deliveries with suction:

Number of deliveries where forceps were used:

Number of C-sections:

Birth weight of largest baby:

Number of episiotomies:

Gynecological History

Date of Last Pap Smear

Date of Last Pap Smear 2

Do you have a history of sexually transmitted infection?

Please specify:

Do you have a history of Yeast Infection (Candida)?

Do you have a history of urinary tract infections?

Any current infection?

Please describe current infection:

Type(s) of intercourse?

Vaginal

Penetrative

Anal

Oral

Other

Please specify:

Do you have pain with sexual intercourse?

Please check if you use any of the following:

Vaginal lubricants

Bath salts, vaginal sprays, and/or deodorant

Latex condoms

Please specify type:

Men's Health History

Have you ever been diagnosed with any of the following? (Check all that apply.)

Prostatitis

BPH

Urinary Tract Infection

Epididymitis

Prostate Cancer

Erectile Dysfunction

Other Urologic Conditions

Other

If "Other," please list diagnosis:

Additional Surgical History

Please check any of the following procedures that you have experienced:

Prostatectomy

TURP

Radiation

Cryosurgery

Other

If "Other," please list type of surgery:

Bladder/Bowel Habits/Problems

Check all bladder/bowel issues that apply:

Trouble initiating urine stream

Urinary intermittent/slow stream

Trouble emptying bladder

Difficulty stopping the uring stream

Dribbling after urination

Straining or pushing to empty bladder

Urge urinary incontinence

Stress urinary incontinence

Blood in urine

Painful urination

Trouble feeling bladder urge/fullness

Current laxative use

Trouble feeling bowel urge/fullness

Constipation/straining

Trouble holding back gas/feces

Recurrent bladder infections

Difficulty wiping clean

Other

If "Other," please describe:

Psychological History

Have you ever been physically, sexually or emotionally abused?

Please explain:

Are you concerned about your safety or the safety of your children?

Please explain:

Are you currently being abused?

Please explain:

What is your current support system?

Employment

Are you working?

Please list your occupation (or previous occupation if retired)

How Do You Learn Best?

How Do You Learn Best Select

What is your preferred language for healthcare discussion:

Do you need interpreter services?

Have You Fallen Over the Past Year?

Have You Fallen Over the Past Year? Question

Yes

Leave this field blank