Casco Bay Physical Therapy

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Casco Bay Physical Therapy 367 US Route 1 Falmouth, ME 04105 (207) 781-5540 (207) 781-5542 (fax) cascobaypt@maine.rr.com Hello and Welcome! Thank you for scheduling an appointment for physical therapy. My mission is to provide specialized physical therapy evaluation and one- on- one treatment in a practical and compassionate manner. I am excited to work with you on a path of rehabilitation. Attached is a comprehensive pelvic floor questionnaire to help me fully understand your symptoms. If you are not sure how to answer a question, leave it blank. We will go through the questionnaire together during your initial evaluation. This packet also includes a general patient information sheet as well as an authorization to pay benefits to provider. Please print and complete all the pages and bring them to your PT evaluation. Thank you, Allison Poole, MPT

Patient History page 0 of 4 Name: DOB: / / Age: yrs. Date: Describe the current problem that brought you here? When did your problem first begin? Was your first episode of the problem related to a specific incident? If yes, please describe, include date: Yes/No Since that time is it (circle one): staying the same getting worse getting better Why or how? If pain is present, rate pain on a 0-10 scale (10 being the worst): Describe the nature of the pain (i.e. constant burning, intermittent ache): Describe previous treatment/exercises: Activities/events that cause or aggravate your symptoms. Check all that apply Sitting greater than minutes With cough/sneeze/straining Walking greater than minutes Standing greater than minutes Changing positions (ie. - sit to stand) Light activity (light housework) Vigorous activity/exercise (run/weight lift/jump) Sexual activity With laughing/yelling With lifting/bending With cold weather With triggers i.e. /key in door With nervousness/anxiety No activity affects the problem Other, please list What makes your symptoms better?

How has your lifestyle/quality of life been altered/changed because of this problem? Rate the severity of this problem from 0-10 with 0 being no problem and 10 being the worst 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 functions Y/N Numbness /tingling Y/N Other /describe Date of Last Physical Exam Tests performed: General Health (please circle): Excellent Good Average Fair Poor Occupation: Hours/week: On disability or leave? Y / N Activity Restrictions? Activity/Exercise: None 1-2 days/week 3-4 days/week 5+ days/week Describe : Mental Health: Current level of stress: High Med Low Current psych therapy? Y/N Medications - pills, injection, patch 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 Anemia Osteoporosis Hypothyroid/ Hyperthyroid Low back pain Chronic Fatigue Syndrome Headaches Sacroiliac/Tailbone pain Fibromyalgia Diabetes Alcoholism/Drug problem Arthritic conditions Kidney disease Childhood bladder problems Stress fracture Irritable Bowel Syndrome Depression Acid Reflux /Belching Hepatitis Anorexia/bulimia Joint Replacement Sexually transmitted disease Smoking history Bone Fracture Physical or Sexual abuse Vision/eye problems Sports Injuries Raynaud s (cold hands and feet) Hearing loss/problems TMJ/ neck pain Pelvic pain Other/Describe: Surgical /Procedure History Y/N Surgery for your back/spine Y/N Surgery for your bladder/prostate Y/N Surgery for your brain Y/N Surgery for your bones/joints Y/N Surgery for your female organs Y/N Surgery for your abdominal organs 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/N Pelvic/genital pain 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 (BM) Y/N Strain or push to empty bladder Y/N Trouble feeling bowel urge/fullness Y/N Difficulty stopping the urine stream Y/N Loss of BM without awareness Y/N Trouble emptying bladder completely Y/N Trouble controlling bowel urge Y/N Blood in urine Y/N Trouble holding back gas/feces Y/N Dribbling after urination Y/N Trouble emptying bowel completely Y/N Constant urine leakage Y/N Support/touch to complete BM Y/N Trouble feeling bladder urge/fullness Y/N Staining of underwear after BM Y/N Recurrent bladder infections Y/N Constipation/straining Y/N Painful urination Y/N Current laxative use Other/describe: page 3 of 4

Describe typical position for emptying:(sitting upright, forward, hovering, etc) 1. Frequency of urination: awake hours times per day, sleep hours times per night 2. When you have a normal urge to urinate, how long can you delay before you have to go to the toilet? not at all 1-3min 4-10min 10-20min 21-60min >1hr 3. The usual amount of urine passed is: small medium large 4. Frequency of bowel movements times per day, times per week, or. 5. The bowel movements typically are: watery loose formed pellets other 6. When you have an urge to have a bowel movement, how long can you delay before you have to go to the toilet? not at all 1-3min 4-10min 10-20min 21-60min >1hr 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 total how many glasses are water? Caffeinated?: Carbonated?: 9. Rate a feeling of organ "falling out" / prolapse or pelvic heaviness/pressure: None present Times per month (specify if related to activity or your menstrual period) With standing for minutes or hours. With exertion or straining Other 10a. Bladder leakage - number of episodes 10b. Bowel leakage - number of episodes Times per day Times per week Times per month Only with physical exertion/cough Times per day Times per week Times per month Only with exertion/strong urge 11a. On average, how much urine do you leak? 11b. How much stool do you lose? Just a few drops Wets underwear Wets outerwear Wets the floor Stool staining Small amount in underwear Complete emptying Other 12. What form of protection do you wear? (Please complete only one) None Minimal protection (tissue paper/paper towel/pantishields) Moderate protection (absorbent product, maxi pad) Maximum protection (specialty product/diaper) Other On average, how many pad/protection changes are required in 24 hours? # of pads

CASCO BAY PHYSICAL THERAPY Patient Information Form Date: Please print: Name: (First) (Last) (M) Address: City: Referring Physician: Primary Care Physician: State: Zip: Date of Birth: Age: Home Phone: Place of Employment: Work Phone: E Mail Address: Cell Phone: Gender: M F In case of emergency contact: Phone: Reason for Referral: Date of injury/onset: Date of Surgery: Work Related: Yes No Auto Accident: Yes No Other Accident: Yes No Patient s Primary Insurance: Policy No: (Insurance Company Name) Patient s Secondary Insurance: Policy No: (Insurance Company Name) Have you been a patient of Casco Bay Physical Therapy before? Yes No Are you presently receiving Home Health services such as nursing, IV therapy, etc? Yes No Have you received speech therapy or physical therapy this year? Yes No How did you hear about us? r Doctor Recommended r Family/Friend r Website r Phonebook r Other: Internal: Reviewed each year:

AUTHORIZATION TO PAY BENEFITS TO PROVIDER: I hereby assign payment directly to Casco Bay Physical Therapy benefits due to me for services rendered. I understand I am financially responsible for any balance remaining after payment of benefits according to my insurance policy. SUPPLIES: I understand that I am financially responsible for all and any supplies that are given to me during the course of my treatment. Payment will be due on the day supply is received. MEDICARE PATIENTS: I have been notified by Casco Bay Physical Therapy that Medicare only covers 80% of all approved charges after which I am personally and fully responsible for the remaining percentage co-payment along with my annual deductible (if it has not been met). As well I have been informed that Medicare has enforced a cap of $1,850.00 per year for physical therapy and speech therapy combined, after which I would be responsible for payment of services. Most medigap insurances will not continue to pay for services denied by Medicare. CANCELLATIONS: Please call 24 hours in advance to cancel your scheduled appointment; otherwise there will be a $35.00 fee to be paid at your next appointment. Thank you for your cooperation. ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I,, have received the Notice of Privacy Practices from Casco Bay Physical Therapy. This notice is dated. Patient Signature: Date:

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