Date: FEMALE INTAKE INFORMED CONSENT FOR ASSESSMENT OF PELVIC FLOOR DYSFUNCTIONS Pelvic floor dysfunctions include pelvic pain syndromes, urinary incontinence, fecal incontinence, dyspareunia or pain with intercourse, pain from an episiotomy or scarring, vulvodynia, vestibulitis or other similar complications. Evaluation of my condition may include observation, soft tissue mobilization, and vaginal or rectal sensors for biofeedback and/or electrical stimulation. I understand it may be beneficial for my therapist to perform a muscle assessment of the pelvic floor, initially and periodically to assess muscle strength, length, and range of motion and scar mobility. Palpation of these muscles is most direct and accessible if done via the vagina and/or rectum. I understand that the benefits of the vaginal/rectal assessment will be explained to me. If I am pregnant, have an infection of any kind, have vaginal dryness, are less than 6 weeks post-partum or post-surgery, have severe pelvic pain, sensitivity to KY jelly, vaginal creams or latex, I will inform the therapist prior to the pelvic floor assessment. Treatment procedures for pelvic floor dysfunctions include, without limitation, education, exercise, stimulation, ultrasound, use of vaginal weights, and several manual techniques including massage, joint and soft tissue mobilization. These procedures, at times, may cause an aggravation of your symptoms. The therapist will explain all these treatment procedures to me and I may choose to not participate with all or part of the treatment plan. I understand that no guarantees have been or can be provided to me regarding the success of therapy I understand that if I am uncomfortable with the assessment or treatment procedures AT ANY TIME, I will inform my therapist and the procedure will be discontinued and alternatives will be discussed with me. Based on the information above, I understand the risks, benefits and alternatives of the treatment. I voluntarily agree to standard assessment and muscular treatment techniques of the perineal area. I am comfortable with only the therapist performing the evaluation in the room. I would prefer to have a chaperone in the room while the therapist performs the evaluation. Patient Signature Therapist Signature Patient s Legal Representative/Guardian/Parent Relationship to Patient Form: 7365005 MPC: 209414 Page 1 of 5
Height: Weight Chief Complaint: When did your symptoms start? What do you think caused your symptoms? How many physicians have you seen regarding this problem? What treatments have you received (medications, therapy, surgery, etc.)? Are you currently receiving Home Health Services? Yes No If yes, explain How much is your problem affecting your quality of life, 0-10 (0 = no effect and 10 = severe impairment)? Pelvic/Abdominal History Kidney Infection Pelvic Pain Pelvic or Abdominal Adhesions Cysts Intestinal Problems Chronic Fatigue Incontinence Vaginal Infection Pelvic Inflammatory Disease (PID) Painful Intercourse STD or Herpes Vaginal Dryness Yes No Yes No Interstitial Cystitis Kidney Stones Hormonal Problems Abdominal Problems Digestive Problems Hemorrhoids Uterine Fibroids Endometriosis Constipation Neurological Disorder Polyps Pelvic/Abdominal Surgical History (i.e. hysterectomy, adhesions, endometriosis, etc.) 1. Date: 2. Date: Date of most recent pelvic exam: What form of birth control do you use? Age when you had your first period? Date of your last period: How often do you have a period (in days)? On average, how long does your period last (in days)? What other symptoms do you experience with your period? Are you sexually active? Yes No If No, Inactive due to PAIN Inactive - other reasons Pregnancy / Labor & Delivery History (if applicable): NA How many pregnancies have you had? Vaginal births? C-Sections? Please list any complications with labor: Did you tear during childbirth? Yes No If yes, how many times? Infertility Issues (if applicable): NA How many tubal pregnancies? How many miscarriages? Have you had any abortions? Have you ever been told that you are infertile? Yes No If yes, how many times? Are you undergoing any treatment for infertility? Yes No If yes, explain? Form: 7365005 MPC: 209414 Page 2 of 5
Bladder Symptoms (if applicable): NA How many times do you urinate during the day? During the night? ICIQ-UI short form: circle your answer A. How often do you leak urine? 0 never 1 about once a week or less often 2 2 or 3 times a week 3 about once a day 4 several times a per day 5 all the time B. We would like to know how much urine you think leaks. How much urine usually leaks (whether you wear protection or not)? 0 None 2 a small amount 3 a moderate amount 6 a large amount When does urine leak? Check your answers Never- urine does not leak Leaks before you can get to toilet Leaks when you cough or sneeze Leaks when you are asleep Leaks when you are physically active/exercising Leaks when you finished urinating and are dressed Leaks for no obvious reason Leaks all the time How many pads do you use? 0 I do not use any pads or panty liners 1 I only use pads during certain activities 2 I use 1 pad per day 3 I use 2-4 pads per day 4 I use more than 4 pads per day 5 I use absorbent undergarments. C. Overall, how does leaking urine interfere with your everyday life? Choose a number between 0 (not at all) and 10 (a great deal) (Not at all) 0 1 2 3 4 5 6 7 8 9 10 (a great deal) / 21 = Sum scores from box A + B + C Bowel Habits: Do you have a history of constipation? Yes No Do you have any fecal leakage? Yes No If yes, how are you managing (pads, etc.)? How often do you have a bowel movement? Per Day? Per Week? Consistency (hard, soft)? Do you experience pain before, during, or after a bowel movement? Yes No Do you have anal fissures of hemorrhoids? Yes No Does anything make your bowels better or worse? Are you currently taking anything (i.e. stool softeners, laxatives)? Yes No If yes, what: What is your daily fluid intake? Have you made any dietary changes? Yes No If yes, what type: Form: 7365005 MPC: 209414 Page 3 of 5
Vulvar & Vaginal Pain (if applicable): NA Please mark with an X where your pain begins. Shade any other areas of pain Urethra (Urine tube) Vagina Rectum/Anus Where is your pain located: How does your pain change during a 24 hour period: Morning: Evening: Night: Any changes relating to activity? Yes No If yes, what are the patterns? What activities does pain interfere with/ prevent you from doing? Describe your pain on a good day: Describe your pain on a bad day: Mark ALL the activities that cause or increase your pain Menstruation Tampon removal Sports activity Wearing pads Friction with clothing Urination after intercourse Finger insertion into vagina Partner manual stimulation Urination in general Oral stimulation by partner Masturbation alone Gynecological Examination with Speculum Tampon insertion Falls Risk Assessment Yes No Are you seeing a physician for dizziness or imbalance? Do you have loss of balance or require assistance when getting up from sitting? Do you have difficulty walking without holding onto furniture or walls? Do you use an assistive device for walking (i.e. cane, walker, wheelchair)? List: How many times have you fallen in the last 3 months? When/how did you last fall? Appointment Guidelines * If you are more than 10 minutes late, you may be asked to reschedule * Cancellations and requests for rescheduling must be given 24 hours before the appointment time * If you cancel more than 3 appointments or you do not show for more than 2 appointments within 10 scheduled sessions for any reason, you will automatically be removed from the therapy schedule and may be discharged. To restart therapy, you will need a new prescription from your physician. Initial Form: 7365005 MPC: 209414 Page 4 of 5
DIAGNOSIS: Emergency Contact Name: Relationship: Phone Number: Medical History: Yes No Yes No Asthma, Bronchitis, Emphysema Shortness of Breath Coronary Artery Disease or Angina Pacemaker High Blood Pressure Heart Attack Stroke/TIA Congestive Heart Disease Blood Clot/Emboli Epilepsy/Seizures Thyroid Disease or Goiter Anemia Infectious Diseases Autoimmune Disease Diabetes Cancer or Chemotherapy/Radiation Gout Severe or Frequent Headache Vision or Hearing Difficulties Numbness or Tingling Dizziness or Fainting Weakness Weight Loss/Energy Loss Hernia Varicose Veins Arthritis Osteoporosis Fibromyalgia Sleeping Problems/Difficulties Emotional/Psychological Condition Are you Pregnant? Do you use Tobacco? Surgeries/Injuries Yes No Yes No Neck/Back Shoulder Elbow/Wrist/Hand Knee Injury/Surgery Leg/Ankle/Foot Joint Replacement Cortisone shot/epidural Internal Stimulator (brain / spine) Heart Surgery Allergies: (List ANY/ALL allergies including latex, drug, environmental, food, skin, etc.) N/A Communicable Diseases: Yes No Do you have active Tuberculosis (TB) or history of TB (even if on meds)? Do you have a history of Methicillin Resistant Staphylococcus Aureus (MRSA)? Do you have a history of Vancomycin-Resistant Enterococci (VRE)? Do you have a history of Clostridium Difficile (C. diff or C. difficile)? Do you have Diarrhea? Medication List: (List ALL meds you are currently taking, include prescribed, over the counter, vitamins, etc.) See attached list I am currently NOT taking any medication including prescribed, over the counter, vitamins, etc. PLEASE INFORM US IF YOU BEGIN TAKING ANY NEW MEDICATIONS DURING YOUR COURSE OF THERAPY Name/Dose Frequency Name/Dose Frequency Form: 7365005 MPC: 209414 Page 5 of 5