Health History

Name

First NameLast Name

Email

example@example.com

Date

Height (ft.)*

you can also type your answer

(in)*

you can also type your answer

Weight (lbs.)*

you can also type your answer

Please answer these questions so that we can better help to address your pelvic heatlh and or sexual health concerns:

How do you prefer to be addressed?*

What pronouns do you use?*

What was your gender assigned at birth?*

What is your preferred gender?*

Are you sexually active?*

What gender do your sexual partners use to identify themselves?*

How do you identify your anatomy so that I can be consistent with your treatment?*

What do you do to make yourself feel good and what do your partners do to make you feel good?*

When did you last have sex and what did you do?*

Are you currently pregnant?*

YESNO

How many times have you been pregnant?

Number of Children:

Number of vaginal delivery:

Any tearing?*

YESNO

Number of Caesarian birth:

Do you have vaginal dryness?*

YESNO

Do you use any personal lubricants*

YESNO

If yes, please list the name: *

Do you have pain with vaginal or anal intercourse?*

YESNO

Do you use any type of lubricant for intercourse?*

YESNO

If yes, please list the name: *

Do you suffer from prolapse of any of the organs of your pelvis?

BLADDERBOWELUTERINE

Do you have urinary incontinence?*

YESNO

Do you have burning with urination?*

YESNO

Do you have chronic vaginal discharge?*

YESNON/A

Do you wear cotton underwear always?*

YESNO

Do you sleep without underwear?*

YESNO

Are you able to have an orgasm with foreplay?*

YESNO

Are you able to have an orgasm with vaginal or anal penetration?*

YESNO

What is your bowel pattern and consistency?*

Please look at/draw on the Bristol Stool Chart to describe the shape and consistency of your BM

Do you have fecal incontinence?*

YESNO

Do you suffer from constipation?*

YESNO

Please list any chronic medical conditions:

Please list any surgeries, including the year it happened:

Do you exercise regularly?*

YESNO

If Yes, what type of exercise and how many days/week?*

Do you smoke?*

YESNO

If YES, how many packs per day?

How many years have you smoked?

How much caffeine do you consume in one day? *

Do you drink carbonated beverages?*

YESNO

How much citrus do you consume in one day? *

How much chocolate do you consume in one day? *

Please list any prescription medication you are currently taking:

Please list any vitamins or supplements that you are currently taking:

Please explain any symptoms you are having and mark on diagram if appropriate

When did your symptoms begin?

What are your goals for treatment?