WomansDPT Intake Form

Name:*
DOB*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age:*
Please list any special instructions I need to be aware of when coming to your home (ex: gate code, parking limitations, etc).
Weight & Height:*
Cell phone:*
Email:*
example@example.com
Preferred method of contact:*
example: email, cell phone, text message
How did you hear about us?*
Name of referring person/source:
Preferred weekday and time for appointment (Ex: Mondays at 11a):
Select one:*

SingleMarriedDivorcedWidowCohabitating
Are you currently working? If so, please describe your profession/responsibilities.*
Medical conditions (list and note when diagnosed):*

Medical History: Please select all conditions that apply to your personal history.

	Yes
Anemia
Back/Neck pain
Cancer
Chronic cough
Congenital Abnormalities
Diabetes
Epilepsy
Fibromyalgia
Heart Disease
Hernia
Hepatitis
High bloood pressure
Irritable Bowel Syndrome (IBS)
Intrauterine Device (IUD)
Lung Disease
Mental illness
Pacemaker
Respiratory Disease
Scoliosis
Sexually Transmitted Disease (STD)
Stroke
Thyroid Dysfunction

Allergies (if none, please type N/A)*
Current medications:*
How many times have you been pregnant?*
How many vaginal deliveries have you had?
How many cesarean deliveries have you had?*
What was the birth weight of your largest baby? Did you lose all the weight you gained from pregnancy?*
Have you "torn" during any deliveries? Please describe all occurences.
Please list all past surgeries, invasive medical procedures, fractures and other serious injuries. Include approximate date and any lasting complications or disabilities:*
Who lives at home with you?*

No one, I live aloneSpouse or significant otherChildrenOther
How would you rate your current health?*

PoorFairGoodExcellent
Describe your typical exercise routine. How often do you exercise (weekly) and what are you doing?*
What was your previous exercise routine (if any)?*
Were you flexible as a child? How does that compare to your flexibility now?
How would you rate your current stress level?*

NoneLowMediumHighVery High
What factors are impacting your current stress level rating?*
Have you received physical therapy at another clinic?*

Yes, currently.Yes, in the past.No
What was the reason you received physical therapy?
Which of the following categories describes the reason you are seeking physical therapy services?*
Please give a brief description of the reason you are seeking physical therapy. When did it begin? Have you been treated in the past for this condition?*
What are your top 2-3 goals for physical therapy?*
Pain Scale:

A= Ache; B= Burning; R= Radiating; D= Dull; N= Numbness; P= Pins & Needles S= Stabbing; O= Other
Using the diagram and scale above, explain the location and description of your pain. Explain what increases your pain and what makes it better. For example: "My back hurts when I bend down to pickup objects. It feels like needles". Skip this question if you don't have pain.
PFM Sensory: Please check any symptoms you have:

numbnessreduced feelingdecreased sensationtinglingincreased sensationpins and needlespainfultenderachingburninguncomfortable
PFM Motor: Please check any symptoms you have:

looselaxgapingsaggingopenweakbulgingfullloss of controltighttensenarrowconstricted
Do you include fiber in your diet? What type?*
How often do you use a laxative?*
How often do you leak urine?*
What form of protection do you use for leakage?

NoneLinersPadsDiapers
How much do you usually leak? (Even if wearing protection?)*

Overall, how much does leaking interfere with your everyday life?*

	1	2	3	4	5	6	7	8	9	10

1 is Not at all, 10 is A great deal

Please answer all of the questions in the following survey. While answering these questions, please consider your symptoms over the last 3 months.

As you answer, if the condition/question is not related to your experience, select "N/A". If you experience the symptoms but they do not impact your experience, select the option "No not at all".
P1. Do you usually experience pressure in the lower abdomen?*

N/A⁯ No not at all⁯ SomewhatModeratelyQuite A Bit
P2. Do you usually experience heaviness or dullness in the pelvic area?*

N/A⁯ Not at allSomewhat⁯ ModeratelyQuite a bit
P3. Do you usually have a bulge or something falling out that you can see or feel in your vagina area?*

N/A⁯ Not at allSomewhat⁯ ModeratelyQuite a bit
P4. Ever have to push on the vagina or around the rectum to have or complete a bowel movement?*

N/A⁯ Not at allSomewhat⁯ ModeratelyQuite a bit
P5. Do you usually experience a feeling of incomplete bladder emptying?*

N/A⁯ Not at allSomewhat⁯ ModeratelyQuite a bit
P6. Ever have to push up on a bulge in the vaginal area with your fingers to start or complete urination?*

N/A⁯ Not at allSomewhat⁯ ModeratelyQuite a bit
POPDI Score
C7. Feel you need to strain too hard to have a bowel movement?*

N/A⁯ Not at allSomewhat⁯ ModeratelyQuite a bit
C8. Feel you have not completely emptied your bowels at the end of a bowel movement?*

N/A⁯ Not at allSomewhat⁯ ModeratelyQuite a bit
C9. Do you usually lose stool beyond your control if your stool is well formed?*

N/A⁯ Not at allSomewhat⁯ ModeratelyQuite a bit
C10. Do you usually lose stool beyond your control if your stool is loose?*

N/A⁯ Not at allSomewhat⁯ ModeratelyQuite a bit
C11. Do you usually lose gas from the rectum beyond your control?*

N/A⁯ Not at allSomewhat⁯ ModeratelyQuite a bit
C12. Do you usually have pain when you pass your stool?*

N/A⁯ Not at allSomewhat⁯ ModeratelyQuite a bit
C13. Experience a strong sense of urgency and have to rush to the bathroom to have a bowel movement?*

N/A⁯ Not at allSomewhat⁯ ModeratelyQuite a bit
C14. Does part of your bowel ever pass through the rectum and bulge outside during or after a bowel movement?*

N/A⁯ Not at allSomewhat⁯ ModeratelyQuite a bit
CRADI-8 Score
U15. Do you usually experience frequent urination?*

N/A⁯ Not at allSomewhat⁯ ModeratelyQuite a bit
U16. Do you usually experience urine leakage associated with a feeling of urgency, that is a strong sensation of needing to go to the bathroom?*

N/A⁯ Not at allSomewhat⁯ ModeratelyQuite a bit
U17. Do you usually experience urine leakage related to coughing, sneezing, or laughing?*

N/A⁯ Not at allSomewhat⁯ ModeratelyQuite a bit
U18. Do you usually experience small amounts of urine leakage (drops)?*

N/A⁯ Not at allSomewhat⁯ ModeratelyQuite a bit
U19. Do you usually experience difficulty emptying your bladder?*

N/A⁯ Not at allSomewhat⁯ ModeratelyQuite a bit
U20. Do you usually experience pain or discomfort in the lower abdomen or genital region?*

N/A⁯ Not at allSomewhat⁯ ModeratelyQuite a bit
UDI-6 Score
PFIQ Score

Select responses below based on the past month. If you don't leak with a certain activity, don't select an answer choice for that specific activity. Do you leak with:*

	Choose an option below
Coughing/Sneezing
Bending down to lift something up
When you walk quickly, jog or exercise?
While you are undressing in order to use the toilet?
Do you get such a strong and uncomfortable need to urinate that you leak urine (even small drops) or wet yourself before reaching the toilet?
Do you have to rush to the bathroom because you get a sudden, strong need to urinate?

Do you have :

	Yes	No
Pain with Sexual Intercourse
Pain with pelvic exam
Pain with tampon use
Pain with menstrual periods
Pain in your back
Pain in your legs
Pain in your abdominals
Any history of trauma to the pelvis
Regular menstrual cycles
History of sexual abuse or trauma
Pain with penetration
Pain with intial entry
Pain with deep thrust
Pain/bleeding after sex

Describe with as much (or as little) detail any special considerations I need to know in working with you:*
How often do you move your bowels each day? Weekly?*
What is your most common stool consistency?*
Privacy Act: I authorize Dr. Valerie Akinwande PT, DPT to release medical or other information necessary to provide my treatment. I understand this information won’t be shared unless necesary and that my personal information is protected under the Privacy act, which this practice abides by. A copy of the HIPPA policy is available online. Please ask Dr. Akinwande if a copy is needed. Patient Initials:*

Clear
Statement of Understanding - Notice of Rights for Secure Communication and Waiver of Those Rights Federal law requires that this practice use secure/encrypted methods when texting or e-mailing patients. At this time, Dr. Valerie Akinwande PT, DPT does not offer a secure/encrypted method to communicate electronically with patients. However, I take patient confidentiality and legal compliance very seriously. • My business phone is a cell phone. • I am the only person using the phone. • I will not be able to answer the phone if I am working with a patient. Please leave a message with your name and phone number. • Email is the best way to reach me quickly. Make sure your full name is included in emails. • At this time, my phone and my email are not secure or encrypted. • I will make every effort to respond to text, phone messages, and emails within 8 hours during the workday or during the morning of the next business day. Please contact me again if I have not responded in 2 days. These communications may/may not include private information (such as name, health condition, or billing/financial information). I understand the risks inherent in using unsecured/unencrypted communications. I acknowledge that I may change my preference below at any time by notifying the practice in writing. Initial only those that apply*
Consent to treat: I consent to physical therapy services at Women’s DPT. In doing so, I understand that such therapy may involve bodily contact, touching and/or direct contact of a sensitive nature. I understand that these procedures will be fully explained before they are provided and that I have the right to refuse or stop any treatment at any time without fear of judgment or other repercussions. For ALL appointments, please make sure any house pets are put up so that they do not interfere with the session. Patient Initials: *

Clear
Attendance policy: Your success in PT depends on keeping your scheduled appointments. Please provide 48-72 hours notice if you need to cancel. This gives me time to call other patients. Failed appointments or those cancelled after 48 hours (before appointment time) will be charged a $150 cancellation fee. If you are not ready for the mobile appointment within 15 minutes of the therapist’s arrival, your appointment will be cancelled and you will be charged the cancellation fee. The second offense will result in a cancellation fee equal to the cost of the appointment. Repeated cancellations will result in re-evaluation of your need for therapy. Medical emergencies or technical difficulties (telehealth) will not be charged the cancellation fee. Payment for services rendered is due on the date of service. Failure to provide payment for services within 3 business days will result in a late payment fee of $50/day and cancellation of future appointments. Please help me to provide the best care possible for you and others: be ready for appointments on time and if necessary; check your Internet connection before your appointment to ensure it is stable and connected. Patient Initials:*

Clear
Due to the COVID-19 outbreak we are taking extra precautions with each client, health history review, as well as sanitation and disinfection practices. Please complete the following and sign below.
Have you experienced any of the following symptoms in the past 48 hours:
- fever or chills
- cough
- shortness of breath or difficulty breathing
- fatigue
- muscle or body aches
- headache
- new loss of taste or smell
- sore throat
- congestion or runny nose
- nausea or vomiting
- diarrhea
Yes/No* Signature
COVID safety measures: To mitigate potential spread, all patients are required to provide their own linens for the therapy session. Please provide 2 flat sheets and 2 pillowcases (any size). Sign below:

Clear
I attest that the information on this form is accurate to the best of my knowledge, and I have read the Health Information Privacy notice provided on the company website and signed the form. I hereby give authorization for the performance of such rehabilitation procedures as permitted by Texas Statutes under the appropriate scope of practice are, in the judgment of my Physical Therapist, deemed necessary. I agree to pay WomansDPT charges for services rendered to me during my course of treatment. If I do not pay for charges that are my responsibility, I agree to pay WomansDPT’s collections costs including attorney and court fees.
Patient signature:*

Clear
Date:*

MonthDayYear
DateHourMinutesAM/PM Option
What type of appointment would you like to schedule?*
Please upload a front and back photo of your driver's license. If you skip this step, you will need to email the copy to womansdpt@gmail.com or have it ready for your first mobile appointment.

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Please upload your referral form if you have one. If you have issues uploading you can also send a copy to womansdpt@gmail.com

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Please verify that you are human*
Incontinence Score
Should be Empty:

Pain Scale: