Patient Intake- Pelvic Floor Therapy
[Male& NIH]
The information in this packet is essential for your provider to have before your first visit. If you find yourself struggling to fill out or submit the paperwork online, please call our office immediately to either come in 30 minutes early to fill it out on paper, or come by and pick up a paper packet. We also have staff members in the clinic that can help you fill out paperwork if needed, we just need to be notified. If we do not hear from you and your paperwork has not been submitted 48 hours before your first appointment, your appointment could be cancelled.
360-279-8323
Today's Date:
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Patient Demographics
Patient Name:
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First Name
Last Name
Date of Birth:
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Year
Age
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Gender?
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Female
Male
Prefer not to answer
Other
Phone Number:
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Please enter a valid phone number.
Social Security Number: Why are we asking? Depending on your benefits and insurance coverage, your SSN may be required.
Do you give R&P permission to communicate with you via email?
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Email:
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Primary Care Physician
Not all physicians that refer patients to us are patients primary care physicians. Please let us know who your primary care physician (PCP):
Primary Care Physician Name:
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First Name
Last Name
PCP Clinic/Facility:
ex. Whidbey Health Medical Center
PCP Contact:
Please enter a valid phone number.
Along with your referring provider, would you like for us to also send all of your therapy rehabilitation records to your PCP?
Yes, I authorize R&P to send my therapy records to my PCP
No, only send records to the physician that referred me to R&P
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Emergency Contact
In case of an emergency, whom should we contact?
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First Name
Last name
Emergency contact relationship to patient:
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Please Select
Spouse
Partner
Parent
Child
Sibling
Grandparent
Grandchild
Legal Guardian
Friend
Other
Emergency contact phone number:
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Please enter a valid phone number.
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Primary Insurance Information
Primary Insurance you wish us to bill for your rehabilitation:
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Please Select
Medicare
Medicare HMO Plan
Tricare (Active Duty, Retired, Tricare for life)
US Family Health Plan
Champ VA
Triwest / VA
Regence
Cigna
Premera
Kaiser Permanente
Aetna
Lifewise
AARP
L&I Claim
Sedgewick
United American Insurance
Auto Insurance
Self-Pay
I do not have Insurance
Not Listed
Primary Insurance Policy/Benefits Number:
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Secondary Insurance Information
Secondary Insurance you wish us to bill for your rehabilitation:
*
Please Select
Medicare
Medicare HMO Plan
Tricare (Active Duty, Retired, Tricare for life)
US Family Health Plan
Champ VA
Triwest / VA
Regence
Cigna
Premera
Kaiser Permanente
Aetna
Lifewise
AARP
L&I Claim
Sedgewick
United American Insurance
Auto Insurance
Self-Pay
I do not have Insurance
Not Listed
Secondary Insurance Policy/Benefits Number:
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Informed Consent to Treat for Pelvic Floor Therapy:
Response to physical and occupational therapy intervention varies from person to person; hence, it is not possible to accurately predict your response to a specific modality, procedure, or exercise protocol. Rue and Primavera does not guarantee what your reaction will be to a specific treatment, nor does it guarantee that the treatment will help resolve the condition that you are seeking treatment for. Furthermore, there is a possibility that the physical and/or occupational therapy treatment may result in aggravation of existing symptoms and may cause pain or injury. It is your right to decline any part of your treatment at any time before or during treatment, should you feel any discomfort or pain or have other unresolved concerns. It is your right to ask your physical therapist about the treatment they have planned based on your individual history, physical therapy diagnosis, symptoms, and examination results. Consequently, it is your right to discuss the potential risks and benefits involved in your treatment. I have read this consent form and understand the risks involved in physical therapy and agree to fully cooperate, participate in all physical therapy procedures, and comply with the established plan of care. I authorize the release of my medical information to appropriate third parties. I, the undersigned patient or patient’s representative, request admission to Rue and Primavera Rehabilitation for care and treatment. I certify that the information given is correct. I am aware that the practice of Rue and Primavera Rehabilitation is not an exact science and acknowledge that no guarantees or promises have been made as to the result of treatment of examination.
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Joint Notice of Privacy Practices Acknowledgment:
We keep a record of the health care services we provided you. You may ask to see and copy that record. You may ask to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your record or get more information about it by contacting our office. Our notice of Privacy Practices describes in more detail how your health information may be used and disclosed, and how you can access your information.
Release of Medical Information:
Please include the name(s) of the person(s) with whom we are allowed to discuss your medical and billing information, please include other medical facilities that you may need us to send information to other than your referring provider:
Name of person we are allowed to discuss medical information with
First/Last Name
Relationship
First/Last Name
Relationship
No Show & Cancellation Policy:
Thank you for choosing Rue and Primavera for your therapy needs. We are happy to be of service to you. Rue and Primavera reserves treatment time exclusively for your benefit. In order for us to help you with your condition it is important that you keep your scheduled appointments. It is not our intention to cause undue financial hardship for you as the patient, however we cannot absorb a loss in revenue due to lack of compliancy. -Late Cancelations: Appointments must be cancelled 24hours PRIOR to your scheduled appointment or there will be a $80.00 fee not covered by your insurance company. We must hear from you during business hours 9-5pm. If you leave a voicemail after hours (including weekends) the fee will be billed to you, as we do not have the chance to fill your cancelled appointment. -No Shows: If you do not show up for your scheduled appointment and do not call to notify us of your absence, you will be charged a fee of $125.00. This fee will not be waived under any circumstances. All fees are due at the time of the next scheduled appointment. This fee also applies to your first appointment. *If you cancel without cause or give late notice 3 times in one month you will be automatically discharged. After your first no-show you will be contacted but all future appointments will be cancelled, and you will have to contact us to get back on the schedule. Out of curtsy we send you a reminder call/text/email 48-hours before your scheduled appointment. We understand there may be times when an unforeseen emergency occurs, and you may not be able to keep your scheduled appointment. If you should experience extenuating circumstances, please contact our Patient Care Coordinator. By my signature below I understand the no-show/cancellation policy and that if I no-show or late cancel my first appointment, R&P will cancel all of my upcoming appointments, assuming this is not the right time for me to start therapy. I understand that last minute (less than 24 hours notice) cancellations due to not having childcare or having another doctors appointment scheduled there will still be a late cancellation fee billed to me that is not covered by insurance. It my responsibility to know when my appointments are. Signature:
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We will now be holding credit cards on file that will automatically be charged in the event you cancel your appointment less than 24 hours beforehand or if you do not show to your scheduled appointment. We will never run your card without attempting to contact you first. All credit cards are kept on WebPT (our HIPAA compliant and secure EMR System), our staff cannot see any card information other than the last four of the card number. WebPT uses Tokenization Service to hold card information. This is a secure company that works with any type of payment in PHI (Protected Health Information) or Health data. I understand this policy:
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Clear
I will...
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Give R&P my credit/debit card at my first appointment
Other
Release of Medical Information/ Financial Agreement/ Assignment of Benefits:
I authorize Rue and Primavera Rehabilitation to release any information necessary to facilitate the processing of healthcare claims, and audit of payments relative to this care. I consent to the release of any information as needed to my referring and primary physician and to other health facilities or agencies as I direct or as required by law. I understand that I have given R&P all valid and up-to-date insurance information and that it is my responsibility to know my benefits. I understand that if my insurance does not cover all of my visit/procedure that I am solely responsible for any unpaid bills. Signature:
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Past Medical History
Please describe the problem that brought you here:
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Have you had any imaging done, related to the area of concern? (ex. MRI, Xray)
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Yes
No
Please select all imaging you have had related to why we are seeing you:
MRI
Xray
Dexascan
Ultrasound
CT
PET
Other
Which body part did you get imaging of?
ex. Hip
When did you have your imaging done?
Where did you have your imaging done?
ex. Island Hospital
When did your problem first begin?
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Month
-
Day
Year
Date
Was your first episode of the problem related to a specific incident?
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Yes
No
Since then is it...
Staying the same
Getting worse
Getting better
Based on your answer from above, why or how?
Rate your level of pain on the scale below 1-10
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Please Select
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10
Describe the nature of the pain (i.e. constant burning, intermittent ache):
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Shade areas of pain/discomfort:
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Describe previous treatment/exercises:
Activities/events that cause or aggravate your symptoms. Check all that apply:
Changing positions (i.e. Sit to Stand)
Light activity (light housework)
Vigorous activity/exercise (running/weightlifting/jumping)
Sexual Activity
With cough/sneeze/straining
With laughing/yelling
With lifting/bending
With cold weather
With triggers-running water/keys in door
With nervousness/anxiety
No activity affects the problem
Other
What relieves your symptoms?
How has your lifestyle/quality of life been altered/changed due to this problem?
Social activities (exclude physical activities), specify:
Diet/fluid intake, specify:
Physical activity, specify:
Work, specify:
Other, specify:
Rate the severity of this problem from 0-10 with 0 being no problem and 10 being the worst:
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Please Select
1
2
3
4
5
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9
10
Since the onset of your current symptoms have you had any of the following? Check all that apply:
Fever/Chills
Unexplained weight change
Dizziness or fainting
Change in bowel or bladder functions
Malaise (unexplained tiredness)
Unexplained muscle weakness
Night pain/sweats
Numbness/Tingling
Other
What are your treatment concerns and/or goals?
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Health History
Date of your last physical exam:
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Month
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Day
Year
Date
Tests that were preformed during your last exam:
General Health:
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Excellent
Good
Average
Fair
Poor
Occupation Title:
Hours a week you work:
On disability or leave?
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Yes
No
Activity restrictions:
Current level of stress:
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High
Medium
Low
Psych Therapy?
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Yes
No
Activity/Exercise:
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None
1-2 Days/Week
3-4 Days/Week
5+ Days/Week
Describe what activity/exercise you do:
Check all that apply:
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Prostate Disorders
Shy Bladder
Pelvic Pain
Erectile Dysfunction
Painful Ejaculation
Other
Have you ever had any of the following conditions or diagnoses? Check all that apply:
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Cancer
Heart Problems
High Blood Pressure
Migraines
Anemia
Low Back Pain
Sacroiliac/Tailbone Pain
Alcoholism/Drug Problem
Childhood Bladder Problems
Depression
Anorexia/Bulimia
Smoking History
Stroke
Epilepsy/Seizures
Multiple sclerosis
Head Injury
Hypothyriod/Hyperthyroid
Chronic Fatigue Syndrome
Fibromyalgia
Osteoporosis
Rheumatoid Arthritis
Joint Replacement
Bone Fracture
TMJ/Neck Pain
Emphysema/Chronic Bronchitis
Asthma
Diabetes
Irritable Bowel Syndrome
Sexually Transmitted Disease
Physical or Sexual Abuse
Pelvic Pain
Allergies
No significant history to effect this problem
Other
Surgical/Procedure History- Please check all that apply:
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Surgery for your back/spine
Surgery for your brain
Surgery for your female organs
Surgery for your bladder
Surgery for your prostate
Surgery for your bones/joints
Surgery for your abdominal organs
None of the above
Other
Please list all surgeries you have had related to your area of concern. Click ADD/SAVE to list another and/or to complete section:
Are you currently taking any medications or supplements?
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Yes
No
Please list all medications & supplements you are currently taking: Click ADD/SAVE to list another and/or to complete section:
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Pelvic Symptoms Questionnaire
Bladder/ Bowel Habits/ Problems
Pelvic Symptom Questionnaire- please check all that apply:
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Trouble initiating urine stream
Urinary Intermittent/ Slow stream
Trouble emptying bladder
Staining or pushing to empty bladder
Dribbling after urination
Constant urine leakage
Blood in urine
Painful urination
Trouble feeling bladder urge/fullness
Current laxative use
Trouble feeling bowel/urge/fullness
Constipations/Straining
Trouble holding back gas/feces
Recurrent bladder infections
None
Other
Frequency of urination: awake hours per day:
Frequency of urination: sleep hours/times per night:
When you have normal urge to urinate, how long can you delay before you have to go to the toilet? Please indicate how many minutes or hours or not at all.
The usual amount of urine passed is:
Small
Medium
Large
Frequency for bowel movements: Times per day?
Frequency for bowel movements: Times per week?
When you have normal urge to have a bowel movement, how long can you delay before you have to go to the toilet? Please indicated how many minutes/hours or not at all:
If constipation is present describe management techniques:
Average fluid intake (on glass 8oz or one cup) per day:
Of the total above, how many glasses are caffeinated per day?
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LEAKAGE/INCONTINENCE
Do you have leakage/incontinence?
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Yes, Bladder Leakage
Yes, Bowel Leakage
Yes, both Bladder and Bowel Leakage
No Leakage/Incontinence
Bladder
Bladder leakage- Number of episodes:
No Leakage
Only with physical exertion/cough
Bladder leakage- times per day:
Bladder leakage- times per week:
Bladder leakage- times per month:
On average, how much urine do you leak?
No leakage
Just a few drops
Wets underwear
Wets outerwear
Wets the floor
Bowel
Bowel leakage- Number of episodes:
No Leakage
Only with physical exertion/cough
Bowel leakage- times per day:
Bowel leakage- times per week:
Bowel leakage- times per month:
How much stool do you lose?
No leakage
Stool straining
Small amount in underwear
Complete emptying
What form of protection do you wear? (please check one)
None
Minimal protection (tissue paper/paper towel/pant shields)
Moderate protections (absorbent product, maxi pad)
Maximum protections (specialty product/diaper)
Other
On average, how many pad/protection changes are required in 24 hours?
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Have you fallen two or more times in the past 12 months?
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Yes
No
Are you here today because of a fall?
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Yes
No
Do you have any problems with walking or balance?
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Yes
No
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What to expect on your first visit for Pelvic Floor Physical Therapy:
A Physical Therapist (PT) with specialized training in pelvic floor muscle dysfunction will perform a detailed evaluation in a private setting during your first visit. This will include understanding your general medical history, history related to your current condition, stress level, preferred activities and lifestyle, and your desired goals. You’ll be asked questions about your eating, drinking, and bathroom habits. Your posture, breathing pattern, strength and motion of your hips, spine and abdominals will be assessed to determine what may be contributing to your symptoms. The muscles of your pelvis (including the pelvic floor) will be evaluated to determine if any weakness, tightness or in-coordination exists that may play a role in your incontinence. An examination of your pelvic floor muscles may consist of an external and/or internal assessment to determine your strength, coordination and tension of these muscles. An internal assessment can also provide the therapist with information regarding any muscular tender spots or trigger points that may need treatment. Know that you can agree or decline any portion of the recommended evaluation. Biofeedback may also be used during the initial visit if determined necessary by your physical therapist. Biofeedback is a non-invasive procedure that measures the activity of your pelvic floor muscles. Biofeedback does not hurt and allows you to see your pelvic floor muscle activity on a computer screen or hand-held unit, to better understand your muscle’s function. Biofeedback may also be used to monitor your progress over time. Your PT will discuss a treatment plan with you that will include the frequency and duration of your PT sessions and planned interventions. Recommended treatments may include: techniques to reduce urinary urgency and frequency, retaining pelvic floor muscles to work correctly, education in bladder irritants and dietary/fluid modifications, exercises that assist with pelvic floor function (may include breathing, hip, back or abdominal muscle exercises), posture instruction, and behavioral/stress management strategies.
I have read the above statement on what to expect for my first Pelvic Floor Therapy visit:
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Informed Consent for Pelvic Floor- Evaluation & Treatment
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 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 backpain, or pelvic pain conditions. I understand that to evaluate my condition 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 conditions, 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 and use of speculum. Treatment may include, but not be limited to the following: observation, palpation, use of vaginal weights, vaginal or rectal sensors for biofeedback and/or electrical stimulation, ultrasound, photo biomodulation, heat, cold, stretching and strengthening exercises, soft tissue and/or join mobilization and education instruction. 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. Cooperation with treatment: I understand that in order for therapy to be effective, I must come in 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 options regarding potential results of physical therapy treatment for my condition and will discuss all treatment options with me before I consent to treatment. I have informed my therapist of any condition that would limit my ability to have an evaluation or to be treated.
A chaperone can be provided and maybe requested by the therapist and/or patient. Please check one:
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I would like a chaperone present during the intimate part of the exam
I decline a chaperone
I have read the above statement and understand the informed consent to treat for Pelvic Floor Therapy:
*
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Before submitting please review the questions above and make sure you have answered them all to the best of your ability.
Paperwork must be filled out completely 48 hours before your first appointment, or the provider will cancel. Thank you, we look forward to seeing you at your first visit.
How has your experience with Rue & Primavera OTPT been so far?
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