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Pilates
Women's Health Physiotherapy
Baby Massage
Live Well Waterford
Personal and professional, physiotherapist-led classes and treatments for both you and your baby
www.livewellwaterford.ie/forms/pelvic-screening-questionnaire
Pelvic Screening Evaluation
To be completed by all clients attending for pelvic physiotherapy assessment.
Session
Private Physiotherapy 1:1 Client
Pilates Class Client
Client Name:
*
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
Mobile Telephone Number:
*
Email Address:
*
Date of Birth
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
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?
*
Please Select...
Yes
No
Are your present complaints due to injury?
*
Please Select....
Yes
No
Other
If yes, please explain:
Have you had previous physiotherapy?
*
Please Select
Yes
No
If yes, please explain:
Have you seen other physicians for this condition?
*
Please Select
Yes
No
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?
*
Please Select....
Yes
No
Are you currently on psychotropic medication or receiving psychological counselling?
*
Please Select
Yes
No
What meaningful activity do you want to do but can't do now?
*
What meaningful activity do you want to do but can't do now?
*
Do you smoke?
*
Please Select
Yes
No
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.
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