Livewell | www.livewellwaterford.ie/forms/pelvic-screening-questionnaire

Session

Client Name:*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mobile Telephone Number:*

Email Address:*

Date of Birth*

GP Name & Address:*

Please outline GP details and note whether they, or another health care practitioner, recommended that you attend Live Well Waterford Clinic.

CURRENT HEALTH REPORT

Reason for attending for physiotherapy treatment

Please take time to outline why you have arranged to attend Live Well Waterford for a physiotherapy assessment. What is your main complaint? When did it start? Please outline any past medical history pertinent to your presenting condition. *You will get more from your consultation if you spend time giving this question some thought and providing specific information*

What are your long term goals in attending this clinic?*

Is your condition getting worse?*

No
Yes
Static

Is your condition interfering with your:*

Work
Sleep
Daily Routine
Other (explain)

If other, please explain:

What activities aggravate your condition?*

What makes you feel better?*

Have you had this or a similar condition before?*

Are your present complaints due to injury?*

If yes, please explain:

Have you had previous physiotherapy?*

If yes, please explain:

Have you seen other physicians for this condition?*

If yes, please explain:

EXERCISE/HABITS OF DAILY LIVING

What is your current exercise level?*

Please Select....
None
Moderate
Heavy

Please use the box below to outline any exercise that you do.

Please provide information relating to duration and intensity. Class or gym workout? If walking or cycling etc, please note the terrain. If you are NOT currently exercising, please note N/A.

Work Activity*

Sitting
Standing
Walking
Light Labour
Heavy Labour
Not currently working

Stress Level:*

High
Moderate
Low

Do you do any stress reduction or relaxation activities?*

Are you currently on psychotropic medication or receiving psychological counselling?*

What meaningful activity do you want to do but can't do now?*

Do you smoke?*

If yes, how much per day?

GENERAL HEALTH HISTORY

List any major accidents, serious falls or injuries (with dates):*

List Surgeries/Hospital Stays (dates)*

List X-rays or special imaging taken in the last 10 years and their dates:*

List of Current Medication*

Please list all current medications, including dosage taken. If not taking any medication, mark not applicable.

Obstetric History*

Obstetric History is important when assessing bowel/bladder/sexual function issues. It is also important when assessing any orthopaedic conditions such as spinal/pelvic/hip pain and when conducting a pregnancy or post natal screening assessment. This is because the pelvic floor, abdominal, spinal and diaphragmatic muscles are all involved in how well your 'core' functions. Please outline information relating to delivery/deliveries e.g. c-section or vaginal delivery, weight of baby, year of birth, any obstetric injury (tears) or episiotomy, any post partum complications. Any history of miscarriage.

Gynaecological History:*

Please note any information that you feel may be pertinent to your current condition e.g. pelvic organ prolapse or other investigations/procedures. Last PAP Smear and Results.

AUSTRALIAN PELVIC FLOOR SCREENING QUESTIONNAIRE: BOWEL AND BLADDER FUNCTION.

The following section will ask you questions relating to your bladder, bowel and sexual function. We ask these questions as it is important for us to screen the pelvic floor. The reason for this is that the pelvic floor forms an integral part of your 'core' muscle function. Some bladder and bowel issues can suggest that the pelvic floor is potentially weak, over-active or injured. If this is the case, it can influence back pain/function as well as general hip and lower limb function. Should you not feel comfortable answering any of the questions, please leave the particular question blank and it may be discussed at your consultation.

Bladder

How many times do you pass urine in a day?

Up to 7
between 8 - 10
between 11 - 15
more than 15

How many times do you get up at night to pass urine?

0 - 1
2
3
More than 3 times

Do you need to hurry or rush to pass urine when you get the urge?

can hold on
occasionally (< 1/week)
frequently (1+/wk)
daily

Does urine leak when you rush or hurry to the toilet or can't make it in time?

not at all
occasionally (< 1/week)
frequently (1+/wk)
daily

Do you leak urine with coughing, sneezing, laughing or exercising?

not at all
occasionally (< 1/week)
frequently (1+/wk)
daily

Is your urine stream (urine flow) weak, prolonged, or slow?

never
occasionally (< 1/week)
frequently (1+/wk)
daily

Do you have a feeling of incomplete bladder emptying?

never
occasionally (< 1/week)
frequently (1+/wk)
daily

Do you need to strain to empty your bladder?

never
occasionally (< 1/week)
frequently (1+/wk)
daily

Do you have to wear pads because of urinary leakage?

none - never
as a precaution
when exercising/during the cold
daily

Do you limit your fluid intake to decrease urinary leakage?

never
before going out
moderately
always

Do you have frequent bladder infections?

no
1-3 /year
4-12 /year
> 1/month

Do you have pain in your bladder or urethra when you empty your bladder?

never
occasionally (< 1/week)
frequently (1+/wk)
daily

Does the urine leakage affect your routine activities like recreation, socialising, sleeping, shopping etc?

Not at all
slightly
moderately
greatly
not applicable

How much does your bladder problem bother you?

Not applicable (I don't have problems)
Not at all
Slightly
Moderatly
Greatly

Bowel Function

How often do you usually empty your bowels?

Every other day
<3 days/ week
<1 / week
>1 / week

How is the consistency of your usual stool?

soft
firm
hard/pebbles
watery
variable

Do you have to strain a lot to empty your bowels?

never
occasionally (< 1/week)
frequently (1+/wk)
daily

Do you use laxatives to empty your bowels?

never
occasionally (< 1/week)
frequently (1+/wk)
daily

Do you feel constipated?

never
occasionally (< 1/week)
frequently (1+/wk)
daily

When you get wind or flatus, can you control it or does wind leak?

never
occasionally (< 1/week)
frequently (1+/wk)
daily

Do you get an overwhelming sense of urgency to empty your bowels?

never
occasionally (< 1/week)
frequently (1+/wk)
daily

Do you leak watery stool when you don't mean to?

never
occasionally (< 1/week)
frequently (1+/wk)
daily

Do you have a feeling of incomplete bowel emptying?

never
occasionally (< 1/week)
frequently (1+/wk)
daily

Do you have to use finger pressure to help empty your bowels?

never
occasionally (< 1/week)
frequently (1+/wk)
daily

How much does your bowel problem bother you?

Not applicable (I don't have problems)
Not at all
Slightly
Moderately
Greatly

Prolapse Symptoms

Do you have a sensation of tissue protrusion or a lump or bulging in your vagina?

never
occasionally (< 1/week)
frequently (1+/wk)
daily

Do you experience vaginal pressure or heaviness or a dragging sensation?

never
occasionally (< 1/week)
frequently (1+/wk)
daily

Do you have to push back your prolapse in order to void?

never
occasionally (< 1/week)
frequently (1+/wk)
daily

Do you have to push back your prolapse to empty your bowels?

never
occasionally (< 1/week)
frequently (1+/wk)
daily

How much does your prolapse bother you?

Not applicable (I don't have problems)
Not at all
Slightly
Moderately
Greatly

Sexual Function

Are you sexually active? *If you are not sexually active, please continue to the next question below and the last question of this section (marked with "*")

No
< 1x/week
1+/week
Daily

If you are not sexually active, please tell us why?

Do not have a partner
I am not interested
My partner is unable
Too painful
Embarrassment due to prolapse/incontinence
Vaginal Dryness
Other

Do you have sufficient natural lubrication during intercourse?

Yes
No

During intercourse vaginal sensation is:

normal/pleasant
minimal
painful
none

Do you ever feel that your vagina is too loose or lax?

never
occassionally
frequently
always

Do you ever feel that your vagina is too tight?

never
occassionally
frequently
always

Do you experience pain during sexual intercourse?

never
occassionally
frequently
always

Do you leak urine during sexual intercourse?

never
occassionally
frequently
always

*How much do these sexual issues bother you?

Not applicable (I don't have problems)
Not at all
Slightly
Moderately
Greatly

Thank you for taking the time to complete this form!

We really appreciate the time that you put in to completing this form. The information provided will very much help your clinican during your initial consultation. We rely on your feedback to help us improve our services. Your input is greatly appreciated.

Live Well Waterford

www.livewellwaterford.ie/forms/pelvic-screening-questionnaire

Pelvic Screening Evaluation

CURRENT HEALTH REPORT

EXERCISE/HABITS OF DAILY LIVING

GENERAL HEALTH HISTORY

AUSTRALIAN PELVIC FLOOR SCREENING QUESTIONNAIRE: BOWEL AND BLADDER FUNCTION.

Bladder

Bowel Function

Prolapse Symptoms

Sexual Function

Thank you for taking the time to complete this form!

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