Patient Information
Name *
Phone *
Date Of Birth
Date Of Birth
Emergency Contact Phone
Emergency Contact Phone
Family Doctor Phone (if known)
Family Doctor Phone (if known)
Referring professional phone number (if known)
Referring professional phone number (if known)
Pelvic Health Questionnaire
The following is very important to our evaluation process. Please fill out the following as specifically as possible to provide us with a clear picture of your present condition.
What concerns you most about this issue?
Please include any medical conditions you have been treated for in the past 12 months.
Medical Conditions:
Enter NONE if you are not on any medications currently!
Pregnancy History:
Currently Pregnant?
If Yes, when is your due date?
If Yes, when is your due date?
Did you experience any of the following during your pregnancy?
Did you exercise during your pregnancy?
Labor and Birth Experience:
Please check all that apply to your births:
Postpartum Recovery:
Pelvic Health Check:
Check any of the following that applies to you now
Lifestyle & Wellness
Have you ever been a victim of abuse?
Over the past month, how would you rate your overall stress level?
Transactional Emails
You can opt to receive emails to keep you informed of new bookings, changes to your bookings, and reminders for upcoming appointments.
News and Special Promotions
Accuracy of Information *
I certify that the above medical information is correct to my knowledge.
Privacy and Sharing of Information *
I authorize the clinic and its associated health professionals to collect my personal and medical information as documented above. In addition, I authorize the clinic and its associated health professionals to communicate with my family doctor and/or referring doctor as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.
Cancellation Policy *
Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in the therapists’ day that could have been filled by another patient. As such, we require a 24-48 hour notice for any cancellations or changes to your appointment. Patients who provide less than 24 hour notice, or miss their appointment, will be charged a cancellation fee of $25 for the first occurrence, $50 for the second, and $75 thereafter.
Consent to Treat *
The term “informed consent” means that the potential risks, benefits, and alternatives of therapy evaluation and treatment have been explained to you. The therapist provides a wide range of services and I understand that I will receive information at the initial visit concerning the evaluation, treatment and options available for my condition. I also acknowledge and understand that I may 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 or low back pain, or pelvic pain conditions. I understand that to evaluate my condition (if related to pelvic floor) it may be necessary, initially and periodically, to have my therapist perform an internal 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. Such evaluation may include vaginal or rectal sensors for muscle biofeedback. Treatment may include, but not be limited to the following: observation, palpation, vaginal or rectal sensors for biofeedback and/or electrical stimulation, heat, cold, stretching and strengthening exercises, soft tissue and/or joint mobilization and educational instruction. (if being seen for a non-pelvic health issue, then pelvic assessment and treatment do not apply) Potential risks: I may experience an increase in my current level of pain or discomfort, or an aggravation of my existing injury. This discomfort is usually temporary; if it does not subside in 1-3 days, I agree to contact my therapist. Potential benefits may include an improvement in my symptoms and an increase in my ability to perform my daily activities. I may experience increased strength, awareness, flexibility and endurance in my movements. I may experience decreased pain and discomfort. I should gain a greater knowledge about managing my condition and the resources available to me. Alternatives: If I do not wish to participate in the therapy program, I will discuss my medical, surgical or pharmacological alternatives with my physician or primary care provider. Release of medical records: I authorize the release of my medical records to my physicians/primary care provider or insurance company. Cooperation with treatment: 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 with 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 therapist. No warranty: I understand that the physical therapist cannot make any promises or guarantees regarding a cure for or improvement in my condition. I understand that my therapist will share with me her opinions regarding potential results of physical therapy treatment for my condition and will discuss all treatment options with me before I consent to treatment.