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1 Patient History Name DOB Age Date Address Phone 1. Describe the current problem that brought you here: 2. When did your problem first begin? 3. Was your first episode of the problem related to a specific incident? YES/ NO Please describe and specify date 4. Since that time is it staying the same getting worse getting better why or how? 5. If the pain is present, rate pain on a 0-10 scale, 10 being the worst Describe the nature of the pain (constant burning, intermittent ache) 6. Describe previous treatment or exercises for this problem 7. Activities/events that cause or aggravate your symptoms. Check all that apply Sitting greater than minutes Walking greater than minutes Standing greater than minutes changing position (sit to stand) Light activity (light housework) Vigorous activity/ exercise (run/weight lift/jump) Sexual activity other: please list With cough/sneeze/strain With laughing/yelling With cold weather With triggers (key in door) With nervousness/anxiety NO activity affects problem 8. What relieves your symptoms?
2 Patient history name: 9. How has your lifestyle/quality of life been altered/changed because of this problem? Social activities (exclude physical activities) Diet/Fluid intake, specify Physical Activity, specify Work, specify Other 10. Rate the severity of this problem on a 0-10 scale (0 being no problem and 10 the worst) 11. What are your treatment goals/concerns? Since the onset of your current symptoms have you had: Y/N Fever/chills Y/N Malaise (unexplained tiredness) Y/N Unexplained weight change Y/N Unexplained muscle weakness Y/N Dizziness or fainting Y/N Night pain/sweats Y/N Change in bowel or bladder function Y/N Numbness/Tingling Date of last physical exam Tests performed General Health: Excellent Good Average Fair Poor Occupation Hours/wk On disability or leave? Activity Restrictions? Activity/Exercise none 1-2days/wk 3-4days/wk 5+days/wk Describe Mental Health Current level of stress High Med Low Current psych therapy? Y/N
3 Patient History Name: Medications Start Date Reason for Taking Over the counter vitamins etc Start Date Reason for Taking Have you ever had any of the following conditions or diagnoses? Circle all that apply Cancer Stroke Emphysema Chronic bronchitis Heart problems Epilepsy/seizures Asthma High Blood Pressure Multiple sclerosis Allergies (list below) Ankle swelling Head Injury Latex Sensitivity Low Back pain Chronic Fatigue Syndrome Hypothyroid/Hyperthyroid Sacroiliac/Tailbone pain Fibromyalgia Headaches Alcoholism/Drug problem Diabetes Kidney disease Irritable bowel syndrome Arthritic conditions Stress fracture Hepatitis Childhood bladder problems Acid Reflux/Belching Bone Fracture Depression Joint Replacement Sports Injuries Anorexia/bulimia Vision/eye problems TMJ/ neck pain Sexually transmitted disease Hearing loss/problems Physical or Sexual abuse Anemia Raynaud's (cold hands and feet) Smoking history Pelvic pain Other: Describe
4 patient history name: Surgical/Procedure History Y/N Surgery for back/spine Y/N Surgery for your brain Y/N Surgery for your female organs Y/N Surgery for your abdominal organs Y/N Surgery for your bladder Y/N Surgery for your bone/joints Other/describe OB/GYN History Y/N Childbirth vaginal deliveries # Y/N Vaginal dryness Y/N Episiotomy # Y/N Painful periods Y/N C-section # Y/N Menopause when? Y/N Difficult childbirth # Y/N Painful vaginal penetration Y/N Prolapse or organ falling out Y Y/N Pelvic/genital pain Y/N Other/ describe Bladder/Bowel Habits/ Symptoms Y/N Trouble initiating urine stream Y/N Blood in stool/feces Y/N Urinary intermittent/slow stream Y/N Painful bowel movements Y/N Difficulty stopping the urine stream Y/N Trouble feeling bowel urge/fullness Y/N Seepage/loss of BM without awareness Y/N Blood in urine Y/N Trouble emptying bladder completely Y/N Dribbling after urination Y/N Trouble holding back gas/feces Y/N Trouble controlling bowel urge Y/N Trouble emptying bowel completely Y/N Constant urine leakage Y/N Need to support/touch to complete BM Y/N Painful urination Y/N Trouble feeling bladder urge/fullness Y/N Recurrent bladder infections Y/N Staining of underwear after BM Y/N Current laxative use-type Y/N Constipation/straining % of time Y/N Other/describe Describe typical position for emptying 1. Frequency of urination: awake hours times/day sleep hours times/day
5 2. When you have a normal urge to urinate, how long can you delay before emptying minutes hours not at all 3. The usual amount of urine passed is: small medium large 4. Frequency of bowel movements times per day times per week other 5. The bowel movements are typically: watery loose formed pellets or other description 6. When you have an urge to have a bowel movement, how long can you delay before you have to go to the toilet: minutes hours not at all 7. If constipation is present describe management techniques 8. Average fluid intake (one glass is 8 oz or one cup) glasses per day. Of this, how many are caffeinated? glasses per day. 9. Rate a feeling of organ falling out /prolapse or pelvic heaviness/pressure None present Times per month (specify if related to activity or menstrual cycle) With standing for minutes hours With exertion or straining Other 10. Bladder leakage number of episodes No leakage Times/day Times/week Times/month Only with physical exertion/cough 11. Bladder leakage No leakage Just a few drops wets underwear Wets the floor 12. Bowel incontinence number of episodes none x/day x/month 13. How much stool do you lose? No leakage Stool staining Small amounts in underwear Complete emptying or Other 14. What form of protection do you wear? (please complete only one) None Minimal protection (tissue paper/paper towel/ pantishield) Moderate protection (absorbent product, maxi pad) Maximum protection (specialty product/diaper) Other 15. On average, how many pad/protection changes are required in 24 hours? # of pads
Patient History. 6. Rate the severity of this problem from 0-10 /10 7. Describe previous treatment/exercises
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