Women s and Men s Health Intake Form Comprehensive Physical Therapy Center

Transcription

1 Name: (Last, First) DOB: Date: Age: Referring Physician: Next Physician Appointment: Today s visit: What is the main reason you came to the office today? When did it start? What treatments have you had so far for this health issue? Medical History: Please list any and all current medical conditions you may have: Please list or attach a list of your current medications and how often you take them including birth control, hormone replacement medications, vitamins, and herbal supplements. Medication Dose Frequency (Schedule) 1. _ 2. _ 3. _ 4. _ 5. _ 6. _ 7. _ 8. _ 9. _ 10. _ Page 1 of 5

2 Please list any past surgeries and dates: 1. _ 2. _ 3. _ 4. _ 5. _ 6. _ Please list any allergies and your reactions to them: Allergy Reaction 1. _ 2. _ 3. _ Past Obstetrical History (if applicable): How many times have you been pregnant: Of these pregnancies, how many were Preterm (premature) deliveries Full term deliveries Miscarriages or abortions Cesarean delivery Forceps or vacuum Weight of largest baby: Past Gynecological History: Are you sexually active? Yes No If No, why not? Please circle any of the follow that you currently have. Heavy menstruation Fibroids (Myomas) Irregular bleeding Sexually transmitted infections (gonorrhea, chlamydia, herpes) Abnormal pap smear Pelvic infection (PID) Ovarian cysts or tumors Other: Social History: Are you? (Circle one): Single Married Domestic Partner Divorced Widowed Other: Who do you live with? Do you currently work? Yes No What is your current/most recent job? Do you exercise? Yes No Describe your current exercise routine: Do you smoke? Yes No If yes, how many per day? Do you drink alcohol? Yes No If yes, how much per week? Do you use any other drugs? Yes No If yes, please list: During the past month, have you been bothered by feeling down, depressed or hopeless? Yes No Have you ever been emotionally, physically, or sexually abused? Yes No If yes, by whom: When? Page 2 of 5

3 Urological History: How many times do you urinate during the day? How much liquid do you drink per day? _ After emptying your bladder do you have the feeling that you have not finished? Yes No Do you experience leakage of urine? Yes No If yes, how long: _ Month (s) _ Years After you urinate, do you have dribbling? Yes No Women s and Men s Health Intake Form How many times do you urinate during the night after you go to sleep? Does the urge to urinate wake you up? Yes No Do you find it difficult to begin urinating? Yes No Do you leak urine when you cough, sneeze or laugh? Yes Do you leak urine with urgency or on the way to the bathroom? Yes No Please CIRCLE if you leak urine during the following situations: Walking Running Urgency Changing from sitting to standing Lying Down Exercise Minimal Activity With Intercourse Straining/lifting Do you use a pad for urine leakage? Yes No When was your last episode of urine leakage? If yes, how many per day? Do you ever wet the bed while sleeping? Yes No What amount of leakage do you experience? (Circle) Drops More than drops Flood Leak continually No Do you have sensation or awareness when you experience leakage of urine? Yes No Bowel Symptoms: How often do you have a bowel movement? Do you strain with a bowel movement? Do you push with a finger in the vagina to assist with a bowel movement? How long can you postpone emptying your bladder when you have the urge to urinate? minutes hours Please CIRCLE the bowel symptoms you are experiencing: Diarrhea Constipation Incontinence Laxative Use Increased Fiber Use Stool softener Use Difficulty controlling formed stools: Fecal soiling Yes No Liquid stools Yes No Flatus gas Yes No Additional Comments: Page 3 of 5

4 Health Review of Systems: Women s and Men s Health Intake Form GENERAL SKIN Yes No Excessive fatigue Yes No Rashes Yes No Weight loss Yes No Recurrent sores Yes No Excessive thirst Yes No Moles that have changed in color / size Yes No Feeling abnormally hot or cold Yes No Swollen glands Yes No Lumps or swelling Yes No Itching NERVOUS SYSTEM HEART Yes No Frequent or severe headaches Yes No Chest pain Yes No Recurrent numbness or tingling of hands/feet Yes No Heart palpitations (irregular heartbeats) Yes No Mood swings, irritability Yes No Discomfort in the chest with exercise or walking Yes No Depression or anxiety Yes No Difficulty breathing Yes No Dizziness Yes No High blood Pressure Yes No Fainting Yes No Anemia EAR, NOSE, THROAT LUNGS Yes No Hearing difficulty Yes No Shortness of breath Yes No Ringing in the ear Yes No Cough Yes No Changes in vision Yes No Wheezing Yes No Change in voice Yes No Coughing up blood Yes No Difficulty swallowing Yes No Difficulty breathing GASTROINTESTINAL URINARY Yes No Constipation Yes No Urine leakage Yes No Diarrhea Yes No Pain with urination Yes No Heartburn Yes No Excessive urinating at night Yes No Frequent nausea and/or vomiting Yes No Bladder infections Yes No Poor appetite Yes No Kidney stones Yes No Blood in stool GYNECOLOGICAL Yes No Pelvic pain Yes No Pain with sex Yes No Pain after sex Yes No Bleeding after sex Yes No Sores or ulcers Yes No Severe cramps with period Yes No Irregular bleeding/ Bleeding between periods Yes No Heavy bleeding Page 4 of 5

5 Consent for Evaluation and Treatment of the Pelvic Floor I acknowledge and understand that I have been referred for evaluation and treatment of pelvic floor dysfunction. Pelvic floor dysfunctions include, but are not limited to, urinary or fecal incontinence, difficulty with bowel, bladder, or sexual functions; painful scars after childbirth or surgery; persistent sacroiliac (SI) or low back pain; or pelvic pain conditions. I understand that to evaluate my condition it may be necessary, initially and periodically, to have my physical therapist perform an internal manual pelvic floor muscle examination. This examination is performed by observing and/or palpating the perineal region including the vagina and/or rectum. This evaluation will assess skin condition, reflexes, muscle tone, length, strength, and endurance, scar mobility, and function of the pelvic floor region internally and/or externally. Such evaluation may include vaginal or rectal sensor for muscle biofeedback. Treatment may include, but not be limited to, the following: observation, palpation, and the use of vaginal weights, vaginal or rectal sensors for biofeedback and/or electrical stimulation, ultrasounds, heat, cold, stretching and strengthening exercises, soft tissue and/or joint mobilization, and educational instruction. I understand that in order for therapy to be effective, I must come as scheduled unless there are unusual circumstances that prevent me from attending therapy. I agree to cooperate and carry out the home program assigned to me. If I have difficulty with any part of my treatment program, I will discuss it with my physical therapist. 1. The purpose, risks, and benefits of this evaluation have been explained to me. 2. I understand that I can terminate the procedure at any time. 3. I understand that I am responsible for immediately telling the examiner if I am having any discomfort or unusual symptoms during the evaluation. 4. I have the option of having a second person present in the room during the procedure. I would like to request to have an additional person present during the examination Patient Name Date Patient Signature Parent/Guardian Signature (if applicable) Therapist Signature Page 5 of 5