If you were not referred by a health professional, but instead recommended by a friend or other source, please note their details in the space provided above.
DETAILS OF DELIVERY
In this section, we hope to gain as much information relating to your delivery as we can. Please take time to think through your birthing experience and answer/explain details as accurately as you can. We understand that some birth experiences can be difficult to review/discuss, but information provided regards length/stages of labour, positions used for delivery, use of pain relief, whether induction was required, any instrumental assistance, information relating to c-section etc can all be very helpful in understanding why you may be experiencing issues in the post-partum period. We are hear to listen to YOUR birth story and help you in the best way we can through restorative physiotherapy and fitness.
Please note the name of the midwife or doctor/consultant that you were under for your obsteric care.
Please use the space above to outline your birth story. Take time to think it through and then outline the events e.g. length/stages of labour, positions used for delivery, use of pain relief, whether induction was required, any instrumental assistance, information relating to c-section etc.
Please note the AGE of each of your other children. Please also note the mode of delivery (vaginal or section) for each child, the weight at birth of each child, and report any previous obstetric injuries (tear/episiotomy) or any complications related to each delivery.
DETAILS OF PREGNANCY
In this section, we hope to gain information relating to your health during your pregnancy. Issues such as pelvic girdle pain or back pain are helpful for us to know about as are any bladder issues such as urinary frequency, urgency or leakage, or bowel issues such as constipation. General activity/exercise levels in pregnancy can be helpful information too.
Please describe where pain was, when it started, whether you sought treatment for it? Note if it improved/worsened with pregnancy. Note if you required a belt or if crutches were used and if so, from what stage in pregnancy. Did you have similar issues in previous pregnancies?
This relates to urinary leakage, frequency or urgency. Bowel issues such as constipation. Sensations of pelvic organ prolapse/heaviness to vagina/fullness to vagina etc.
Please use space above to explain or simply mark 'not applicable' if no complications to report.
CURRENT HEALTH REPORT
Please outline why you have arranged to attend for a post natal physiotherapy assessment. Please answer accurately.
If you are attending due to pain or specific other issues, please note what activities make your pain/complaint worse. IF you have no pains/issues, but are instead attending to get screened an optimise your current function, then simply mark 'not-applicable' above.
EXERCISE/HABITS OF DAILY LIVING
Please provide information relating to duration and intensity. Walking with a buggy? Class or gym workout? If you are NOT currently exercising, please state this.
GENERAL HEALTH HISTORY
Please list all current medications, including dosage taken. If not taking any medication, mark not applicable.
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 as part of a comprehensive post natal consultation. 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. WE REALLY APPRECIATE YOUR TIME FOR COMPLETING THIS FORM. It helps your clinician provide the most effective and comprehensive consultation for you.
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.