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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
Post Natal Screening Evaluation
Post Natal Screening Evaluation
To be completed by all clients attending for post-natal screening assessment.
Session
*
Please Select....
Private Physiotherapy Client
Post Natal Pilates Class Participant
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
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Belize
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Bolivia
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Brunei
Bulgaria
Burkina Faso
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Cape Verde
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Chad
Chile
China
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Comoros
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Congo, Republic of the
Costa Rica
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Madagascar
Malawi
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Maldives
Mali
Malta
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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
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Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
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Sierra Leone
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Slovakia
Slovenia
Solomon Islands
Somalia
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Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
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Tanzania
Thailand
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Tonga
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Tunisia
Turkey
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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
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4
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31
Year
2024
2023
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1936
1935
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1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
GP Name & Address:
*
Were you referred by a medical/health professional?
*
Please Select
Yes
No
If yes, please note details of health professional
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.
Obstetric Care Team:
*
Please note the name of the midwife or doctor/consultant that you were under for your obsteric care.
Date of delivery
*
Was this a singleton or multiple birth?
*
Mode of Delivery
*
Please Select
Vaginal Delivery
Caesarian Section - Planned
Caesarian Section - Emergency
Details of Delivery/YOUR BIRTH STORY
*
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.
Was this your first delivery?
*
Please Select
Yes
No
If no, please provide further details of your obstetric history.
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.
Did you have spinal or pelvic pain during your pregnancy?
*
Please Select
Yes
No
If yes, please explain:
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?
Did you have any bladder or bowel issues during your pregnancy?
*
Please Select
Yes
No
If yes, please explain:
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.
Did you exercise during your pregnancy?
*
Please Select
Yes
No
If yes, please provide brief outline of exercise undertaken:
Did you have any other complications during pregnancy that you wish to share/outline?
Please use space above to explain or simply mark 'not applicable' if no complications to report.
CURRENT HEALTH REPORT
Reason for attending a post-natal screening assessment:
*
Please outline why you have arranged to attend for a post natal physiotherapy assessment. Please answer accurately.
What are your long term goals in attending this clinic?
*
What activities aggravate or improve your condition/complaint?
*
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.
Have you had this or a similar condition before?
*
Please Select...
Yes
No
Not applicable
Are your present complaints due to injury?
*
Please Select....
Yes
No
Other
Not applicable
If YES or OTHER, please explain:
Have you seen other physicians for this condition?
*
Please Select
Yes
No
Not applicable
If yes, please explain:
EXERCISE/HABITS OF DAILY LIVING
What is your current exercise level?
*
None
Moderate
Heavy
Please use the box below to outline any exercise that you do.
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.
Do you do any stress reduction, relaxation or mindfulness 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?
*
GENERAL HEALTH HISTORY
Do you have any of the following?
*
low back pain
pelvic girdle pain
another spinal condition
muscle or joint conditions
High Blood Pressure
Low Blood Pressure
Circulatory problems e.g. clots
Type 1 Diabetes
Type 2 Diabetes
Incompetent Cervix
Anaemia
Epilepsy
Serious heart, respiratory, renal or thyroid disease
NONE OF THE ABOVE
If you checked any of the above, please explain
List of Current Medication
*
Please list all current medications, including dosage taken. If not taking any medication, mark not applicable.
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 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.
Bladder Function
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.