Live Well Waterford

Personal and professional, physiotherapist-led classes and treatments for both you and your baby

Post Natal Screening Evaluation

To be completed by all clients attending for post-natal screening assessment.

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:*
Were you referred by a medical/health professional?*
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?*
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?*
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?*
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?*
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?*
Are your present complaints due to injury?*
If YES or OTHER, 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?*
- 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?*
Are you currently on psychotropic medication or receiving psychological counselling?*
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.

Live Well Waterford

Post Natal Screening Evaluation

Post Natal Screening Evaluation

DETAILS OF DELIVERY

DETAILS OF PREGNANCY

CURRENT HEALTH REPORT

EXERCISE/HABITS OF DAILY LIVING

GENERAL HEALTH HISTORY

AUSTRALIAN PELVIC FLOOR SCREENING QUESTIONNAIRE: BOWEL AND BLADDER FUNCTION.

Bladder Function

Bowel Function

Prolapse Symptoms

Sexual Function

Thank you for taking the time to complete this form!

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