PHYSICAL THERAPY GENERAL HEALTH QUESTIONNAIRE
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1 PHYSICAL THERAPY GENERAL HEALTH QUESTIONNAIRE Name: Why are you here? Check all the Conditions that apply to you: HEART/CIRCULATION MEDICAL PROBLEMS CHILDBEARING HISTORY Heart Disease/Surgery Diabetes Are you Pregnant? If yes, what is your due date: High Blood Pressure Melanoma # of Children (circle one number) Pain/tightness in chest Cancer # of Vaginal deliveries (circle) Cold Hands Dizziness # of C-Sections (circle one number) Cold Feet Thyroid Problems # of episiotomies (circle one number) Numbness in hands/feet Falls the last 6 mos. # trips/slips/near falls # of forceps deliveries BONES & JOINTS Depression GYNECOLOGICAL HISTORY Chronic Fatigue Syndrome Lupus Date of Last Pap Smear: Arthritis Fibromyalgia LUNG/BREATHING History of Yeast Infections History of Candida Tailbone pain Shortness of Breath Smoke cigarettes now History of Genital Herpes Do you have any current infections or yeast AREAS OF PAIN Back Neck/shoulders Rectum Abdomen/belly Vagina Vulvar Tissue ALLERGIES Ragweed Food allergies Latex allergies Seasonal Allergies SKIN CONDITIONS Eczema Contact Dermatitis Psorasis Lichens Simplex Other History of smoking SURGICAL HISTORY Back or neck Tubal Ligation Laproscopy Abdominal Hysterectomy Vaginal Hysterectomy Gall Bladder Bladder surgery Pelvic Surgery Vaginal Surgery/laser Vulvar Surgery FAMILY HISTORY Skin cancer Allergies Do you use Bath salts Do you use vaginal foams, sprays, deodorants Do you use a spermicide Do you use vaginal lubricants? Do you use latex condoms Do you use KY jelly vaginally URINARY/BLADDER HISTORY Do you urinate more than once every 2 hours? Do you have a sense of urgency to urinate? Do you have symptoms of leaking urine Do you have interstitial cystitis BOWEL HISTORY Do you have Irritable Bowel Syndrome Do you leak gas or feces Do you have constipation LIST ALL THE MEDICATIONS YOU ARE TAKING, INCLUDING HERBAL AND OVER THE COUNTER MEDICATIONS: Name of Medication For what? Name of Medication For What?
2 SOCIAL, OCCUPATIONAL AND RECREATIONAL ACTIVITIES Marital Status: Single Married Separated Divorced Dating Do you feel safe at home? Comment: Occupation: Physically this means I sit stand walk most of the day Educational Level Hobbies: EXERCISE HISTORY: exercise Walk Go to gym Other CHECK THE WORDS THAT APPLY TO HOW YOU FEEL THESE DAYS &/OR CHOOSE YOUR OWN WORDS: DESCRIPTOR Happy Calm Unmotivated Stressed Lonely Content Depressed Overwhelmed Sad Tired Afraid Energetic Optimistic Postpartum blues Flabby Strong Un-rested Lethargic Weak Overworked t bonding with baby(ies) Anxious Unsafe Abused Neglected HOW DO YOU LEARN?: Listening (lecture, discussion) Seeing (read, video, DVD) Doing (practicing skill) Is English your primary language?. If no, would you need a translator when you are in therapy? NUTRITION: How much do you weigh? pounds Would you like to lose or gain weight? Have you gained/ lost more than 10 pounds in the last year? Are you on any special diet? Low Carb Atkins South Beach Weight Watchers Diabetic Other Would you say your diet is unhealthy? too many fast foods t enough vegetables High Fat High Carb Other FLUID INTAKE: What do you drink every day? 8 ounce glasses of water cans of diet soda cans of regular soda 8 ounce cups of regular coffee 8 ounce cups of decaffeinated coffee 8-ounce cups/glasses of tea 16-ounce cans of beer glasses of wine glasses of liquor 8-ounce glasses of milk 8-ounce glasses of juice Other Anything else you would like us to know about you?
3 TELL US ABOUT YOUR VULVAR AND VAGINAL PAIN Please mark with an X where your pain begins. Shade any other areas of pain Urethra (Urine tube) Vagina Vulvar Vestibule Perineal Body (area of episiotomy) Rectum/Anus CURRENT SEXUAL ACTIVITY: Sexually Inactive due to PAIN Sexually inactive for other reasons Sexually active If you are sexually active, continue with this section. pain with intercourse Pain with intercourse, able to complete sex Pain with intercourse disrupts or prevents sex Pain with intercourse prevents any attempt to have sex Tolerate manual or oral stimulation only/no penetration CHECK ALL THE ACTIVITIES THAT CAUSE OR INCREASE YOUR PAIN: Gynecological Examination with Speculum Urination after intercourse Finger insertion into vagina Tampon insertion Tampon removal Partner manual stimulation Friction with clothing Sports activity Urination in general Oral stimulation by partner Masturbation alone Wearing pads Other CHECK THE WORDS THAT DESCRIBE YOUR PAIN: Hot Burning Scalding searing Sharp Cutting Tearing Other Tiring Exhausting frightful punishing grueling suffocating sickening Other Annoying Troublesome miserable intense unbearable discomforting Other WHAT MAKES YOUR PAIN BETTER: Heating pad Ice pack Resting in bed Resting in Chair Medication Cream Abstaining from sexual intercourse t using tampons t wearing tight clothes other WHAT TREATMENTS HAVE YOU HAD FOR THIS PROBLEM? ne or: TREATMENTS HAS IT HELPED? TREATMENTS HAS IT HELPED? Medication(s) A little Surgery A little Treatment for Yeast (describe treatment) A little Physical Therapy A little Other A little What started this problem?
4 VULVAR PAIN FUNCTIONAL QUESTIONNAIRE (V-Q) These are statements about how your pelvic pain affects your everyday life. Please check one box for each item below, choosing the one that best describes your situation. Some of the statements deal with personal subjects. These statements are included because they will help your health care provider design the best treatment for you and measure your progress during treatment. Your responses will be kept completely confidential at all times. 1. Because of my pelvic pain 3 I can t wear tight-fitting clothing like pantyhose that puts any pressure over my painful area. 2 I can wear closer fitting clothing as long as it only puts a little bit of pressure over my painful area. 1 I can wear whatever I like most of the time, but every now and then I feel pelvic pain caused by pressure from my clothing. 0 I can wear whatever I like; I never have pelvic pain because of clothing. 2. My pelvic pain 3 Gets worse when I walk, so I can only walk far enough to move around in my house, no further. 2 gets worse when I walk. I can walk a short distance outside the house, but it is very painful to walk far enough to get a full load of groceries in a grocery store. 1 Gets a little worse when I walk. I can walk far enough to do my errands, like grocery shopping, but it would be very painful to walk loner distances for fun or exercise. 0 My pain does not get worse with walking; I can walk as far as I want to 0 I have a hard time walking because of another medical problem, but pelvic pain doesn t make it hard to walk. 3. My pelvic pain 3 Gets worse when I sit, so it hurts too much to sit any longer than 30 minutes at a time. 2 Gets worse when I sit. I can sit for longer than 30 minutes at a time, but it is so painful that it is difficult to do my job or sit long enough to watch a movie. 1 Occasionally gets worse when I sit, but most of the time sitting is comfortable. 0 My pain does not get worse with sitting, I can sit as long as I want to. 0 I have trouble sitting for very long because of another medical problem, but pelvic pain doesn t make it hard to sit. 4. Because of pain pills I take for my pelvic pain 3 I am sleepy and I have trouble concentrating at work or while I do housework. 2 I can concentrate just enough to do my work, but I can t do more, like go out in the evenings. 1 I can do all of my work, and go out in the evening if I want, but I feel out of sorts. 0 I don t have any problems with the pills that I take for pelvic pain. 0 I don t take pain pills for my pelvic pain. 5. Because of my pelvic pain 3 I have very bad pain when I try to have a bowel movement, and it keeps hurting for at least 5 minutes after I am finished. 2 It hurts when I try to have a bowel movement, but the pain goes away when I am finished. 1 Most of the time it does not hurt when I have a bowel movement, but every now and then it does. 0 It never hurts from my pelvic pain when I have a bowel movement.
5 6. Because of my pelvic pain 3 I don t get together with my friends or go out to parties or events. 2 I only get together with my friends or go out to parties or events every now and then. 1 I usually will go out with friends or to events if I want to, but every now and then I don t because of the pain. 0 I get together with friends or go to events whenever I want, pelvic pain does not get in the way. 7. Because of my pelvic pain 3 I can t stand for the doctor to insert the speculum when I go to the gynecologist. 2 I can stand it when the doctor inserts the speculum if they are very careful, but most of the time it really hurts. 1 It usually doesn t hurt when the doctor inserts the speculum, but every now and then it does hurt. 0 It never hurts for the doctor to insert the speculum when I go to the gynecologist. 8. Because of my pelvic pain 3 I cannot use tampons at all, because they make my pain much worse. 2 I can only use tampons if I put them in very carefully. 1 It usually doesn t hurt to use tampons, but occasionally it does hurt. 0 It never hurts to use tampons. 0 this question doesn t apply to me, because I don t need to use tampons, or I wouldn t choose to use them whether they hurt or not. 9. Because of my pelvic pain 3 I can t let my partner put a finger of penis in my vagina during sex at all. 2 My partner can put a finger or penis in my vagina very carefully, but I still hurts. 1 It usually doesn t hurt if my partner put a finger or penis in my vagina, but every now and then it does hurt. 0 It doesn t hurt to have my partner put a finger or penis in my vagina at all. 0 This question does not apply to me because I don t have a sexual partner. 0 Specifically, I won t get involved with a partner because I worry about pelvic pain during sex. 10. Because of my pelvic pain 3 It hurts too much for my partner to touch me sexually even if the touching doesn t go in my vagina. 2 My partner can touch me sexually outside the vagina if we are very careful 1 It doesn t usually hurt for my partner to touch me sexually outside the vagina, but every now and then it does hurt. 0 it never hurts for my partner to touch me sexually outside the vagina 0 This question does not apply to me because I don t have a sexual partner 0 Specifically, I wont get involved with a partner because I worry about pelvic pain during sex. 11. Because of my pelvic pain 3 It is too painful to touch myself for sexual pleasure. 2 I can touch myself for sexual pleasure if I am very careful. 1 It usually doesn t hurt to touch myself for sexual pleasure, but every now and then it does hurt. 0 It never hurts to touch myself for sexual pleasure. 0 I don t touch myself for sexual pleasure, but that is by choice, not because of pelvic pain Kathi Hummel-Berry, PT, PhD, Kathe Wallace, PT, Hollis Herman MS, PT, OCS All providers of women s health services are hereby given permission to make unlimited copies for clinical use.
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