Patient History Form

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Outpatient Rehabilitation 1000 Fowler Way, Suite 6 Placerville, CA 95667 T: 530-344-5430; F: 530-344-5431 Patient History Form Please fill in the following questionnaire to the best of your ability. The therapists will review your answers with you at your appointment. 1. Please describe the problems that brought you to this appointment: 2. When did your problem first start? 3. Do you have a history of similar problems? 4. Was your problem related to a specific incident? If so, please describe. 5. Are your symptoms: staying the same getting worse getting better? Please describe: 6. Occupation: Circle all that apply: Fulltime/Part- time/volunteer/retired/unemployed/leave/disability 7. How has this problem impacted your daily social/physical/work activities? 8. Amount/type of weekly exercise 9. Current level of stress (circle one): Low Medium High Currently in behavioral health therapy? Y/N. 10. How severe is your problem on a 1-10 scale (1 = no problem, 10 = the worst) 11. How would you rate your pain on a 1-10 scale (1 = no problem and 10 = bad enough for an ER trip).?

12. How would you describe your pain and where is it located? 13. Do you have pain or increased difficulty with any activities: Check or circle all that apply. Prolonged sitting greater than minutes Prolonged standing greater than minutes Walking greater than minutes Turning in bed Standing up from a chair Getting on and off the floor Light activity (laundry/cleaning/cooking) Heavy activity/exercise (running, jumping, dancing, lifting weights) Sexual intercourse/activity With cough/sneeze/straining With laughing/shouting With bending/reaching With cold weather Hearing running water With nervousness/anxiety Other, 14. Is there anything that makes your symptoms better? 15. Do you have a previous history of similar symptoms? 16. Describe any previous treatment/exercises: Did you benefit with previous treatment? Y/N 17. What are your goals for physical therapy? Bladder/Bowel Habits/Problems Y/N Trouble initiating urine stream stream Y/N Trouble emptying bladder stream Y/N Straining or pushing to empty bladder Y/N Urinary intermittent/slow Y/N Difficulty stopping the urine Y/N Dribbling after urination

Y/N Constant urine leakage Y/N Blood in urine Y/N Painful urination Y/N Current laxative use Y/N Trouble feeling bladder urge/fullness Y/N Pain with full bladder Y/N Trouble feeling bowel/urge/fullness Y/N Trouble holding back gas/feces Y/N wetting the bed Y/N Urge to urinate (mild/moderate/strong) Y/N Recurrent bladder infections; if yes then how many per year Y/N Feel unable to empty your bladder completely 1. Frequency of urination: # of times per day # of times per night 2. How long can you delay urinating before having to go to the restroom? minutes hours not at all 3. How much urine do you usually pass? small medium large 4. Frequency of bowel movements # of times per day, # of times per week, or 5. How long can you delay having a bowel movement once you have an urge before having to go to the restroom? minutes hours not at all 6. If constipation is present please describe management techniques: 7. Average fluid intake (1 glass = 8 ounces = 1 cup) glasses per day Of this total how many glasses are caffeinated? glasses per day Skip questions if no leakage/incontinence 8. Bladder leakage: number of episodes Times per day Times per week Times per month Only with physical exertion/cough/laugh/sneeze/lift 9. On average, how much urine do you leak? Just a few drops

Wets underwear Wets outerwear Wets the floor 10. Bowel leakage: number of episodes Times per day Times per week Times per month Only with physical exertion/cough/laugh/sneeze/lift 11. Rate of feeling of organ falling out /prolapse or pelvic heaviness/pressure: None present Times per month (specify if related to activity or your period) With sitting for minutes or hours With standing for minutes or hours With exertion or straining Other 12. How much stool do you lose? Stool staining Small amount in underwear Complete emptying 13. What form of protection do you wear? None minimal protection (Tissue paper/paper towel/pant shields) 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 Surgical/Procedure History Y/N Surgery for your back/spine Y/N Surgery for your brain Y/N Surgery for your female or male organs Y/N Surgery for your bladder/prostate Y/N Surgery for your bones/joints Y/N Surgery for your abdominal organs Other/describe: Ob/Gyn History (females only) Y/N Childbirth vaginal deliveries # Y/N C-Section # # Y/N Prolapse or organ falling out Y/N Vaginal itching Y/N Menopause: when Y/N Episiotomy # Y/N Difficulty childbirth Y/N Vaginal dryness Y/N Painful periods

Y/N Painful vaginal penetration Y/N Pelvic pain Y/N Miscarriages Y/N Abdominal pain Males only Y/N Prostate disorder Y/N Shy bladder Y/N Pelvic pain Y/N Erectile dysfunction Y/N Painful ejaculation Y/N Other/describe General Health History Date of Last Physical Exam Tests Performed and results: Y/N Urodynamics test: Y/N Cystoscope: Y/N Urine test: Y/N Bowel test: Other: Since the onset of your current symptoms have you had any of the following occur? (Please circle all that apply) Y/N Unexplained weight change Y/N Night pain/sweats Y/N Fever/chills Y/N Muscle weakness Y/N Unexplained tiredness Y/N Dizziness or fainting Y/N Numbness or tingling Y/N Change in bowel or bladder functions Y/N Other

Have you ever had or have any of the following conditions or diagnoses (Please circle all that apply): Medications (pills, patches, injections, creams/ointment, over the counter, vitamins) or bring attached list Cancer Heart problems High blood pressure Ankle swelling Anemia Low back pain Sacroiliac/Tailbone pain Alcoholism/Drug Problem Childhood bladder problems Depression Anorexia/bulimia Smoking history Vision/eye problems Hearing loss/problems Stroke Foot pain: right or left Ankle pain: right or left Hand pain: right or left Wrist pain: right or left Epilepsy/seizures Multiple sclerosis Head injury Osteoporosis Chronic Fatigue Syndrome Fibromyalgia Acidic reflux/belching Emphysema Chronic Bronchitis Asthma Diabetes Kidney disease Thoracic, upper back, or rib pain Stress fracture Shoulder pain: right or left Knee pain: right or left Hip pain: right or left Arthritic conditions Joint replacement Bone fractures Sports injuries TMJ/neck pain Allergies Latex sensitivity Glue or lotion sensitivity Hypothyroid/hyperthyroid Headaches Hepatitis STD (Sexually transmitted disease) Physical or Sexual abuse HIV/AIDS Raynaud s (cold hands/feet) Pelvic pain PTSD BPV Other:

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