Pelvic Floor Intake Form

Rate the pain

	1	2	3	4	5

1 is None Usually, 5 is Needs Medical Attention

Where?
Any actions/ circumstances that worsen pain?
Past Medical History
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

	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:
BLADDER/BOWEL HEALTH

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

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

How often do you:

	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?
Should be Empty:

Pain