Pelvic Floor Intake Form

PELVIC FLOOR INTAKE FORM --Female

Name

First NameLast Name

Preferred Name/pronoun

Date of Birth

Date

Date when problem(s) began, if you know

Date

Referral, if applies

Goal for Yoga Therapy

ActiveSedentary

Preferred Exercise

Type

Exercise Hours per Week

WeeklyMonthlyYearlyNever

Hours of Sleep per WEEK

Total hours in a week

YesNo

How many pads do you use for urine collection per week?

YesNo

How many pads do you use for fecal collection per week?

How many cups of caffeine per day?

CoffeeTeaSodaOther

Daily Intake of other fluids

Ounces

YesNo

What worsens the pain?

YesNo

sexual playfeminine hygiene productspessaryOther

YesNo

What worsens the pain?

YesNo

Is the pain regular or constant? Please explain:

Rate the pain

	1	2	3	4	5

1 is None Usually, 5 is Needs Medical Attention

Where?

Any actions/ circumstances that worsen pain?

Do you have any of the following?

Please leave blank if it does not apply.

Reoccurring Muscles/Joint Pain

Where?

Osteoporosis/Arthritis

Where?

Anxiety/Mental Illness

Specify

Breathing Problems/Respiratory Dysfunction

Specify

Thyroid Condition

Specify

Semi-/Professional Athlete

Specify

Surgeries: Hysterectomy/C-Section/Gall Bladder/Appendix/Hernia/D&C/other

Specify and Date?

Endometriosis/Cysts/Fibroids

Date/s

Urinary Tract Infections/Pelvic Inflammatory Disease

Date/s

Ceased mensus

Date

Hormone Replacement Therapy

Date/s

Infertility/Spontaneous Abortion

Specify

Organ Prolapse

Specify

Births

Rows	Date	Weight	Delivery	Length of Labor	Complications in Labor	Complications Post-Delivery
1
2
3
4
5
6

Any other past event/medical intervention that attributes to pelvic weakness/imbalance/tension?

Is there a pattern/acute presence of mental negativity that corresponds with imbalances in the pelvis?

List medications (prescription and over-the-counter) that are being used to treat related symptoms:

List medications (prescription and over-the-counter) that may contribute to pelvic symptoms:

Rows	Daytime	Nighttime
Urination (times per day)
Bowel Movements (times per day)

Rows	Times per Day	Total Times Per Week	Amount
Urinary Leakage
Fecal Leakage

How often do you:

Rows	Multiple times Daily	Daily	Weekly	Monthly	Never	Comment
Wet the bed
Leak Urine when cough/sneeze/jump/turn/lift heavy things/other (specify)
Leak upon standing/on way/at restroom
Leak during/after intercourse
Have urgency when excited/nervous/in hurry/hear water/other (specify)
Have urgency upon standing
Have slow urine stream
Have difficulty beginning urination
After urinating do not feel empty
Have difficulty beginning bowel movement
Have small/hard stool
Have loose stool
Use laxatives/gas relief/anti-diarrheal
After bowel movement do not feel empty
Unable to control release of gas

Have you stopped/limited doing any behaviors/activities because of fear of leakage/urgency?

How much warning time to you have to urinate?

How much warning time to you have to have a bowel movement?

I care about your health and improved function. Is there any other support I can connect you with?

Current Lifestyle

Pain

Past Medical History

BLADDER/BOWEL HEALTH