New Patient Form

Welcome to Pelvic Health Support. Our aim is to provide the expertise, guidance, environment, and therapeutic treatment necessary to help you achieve your goals and enhance your ability to return to a pain-free and active lifestyle. People are referred to Pelvic Health Support for advanced wellness services to provide help for complex problems that have failed to respond to conventional medications, surgery, and therapeutic treatments. As a family nurse practitioner with a specialty in pelvic and sexual health, Pelvic Health Support is dedicated to the comprehensive delivery of the highest quality of care utilizing a multifaceted approach for lasting results.

We request that all patients extend a courteous 24-hr cancellation notice to change or cancel any appointment. If less than 24-hours notice given, 100% of the full session fee will apply. We appreciate your cooperation and courtesy in keeping your scheduled appointment times as well as notifying us of any delays (please refer to the Cancellation Policy form as you complete it). The patient will also be charged the fee for the entire scheduled appointment regardless of the time the patient arrives.

All of your information is on a HIPPA compliant electronic platform.

PATIENT DEMOGRAPHICS

Patient Name

First NameLast Name

Patient Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Preferred pronouns

Marital Satus

Age

Date of Birth*

Date

Primary Phone Number*

Please enter a valid phone number.

MOBILEHOME

Email

example@example.com

Emergency Contact

First NameLast Name

Relationship to Patient?

Phone Number

Please enter a valid phone number.

How did you hear about Pelvic Health Support?

Who is your primary care provider?

CANCELATION POLICY

The scheduling of an appointment involves the reservation of time specifically for you. In the event of a “no show” or failure to give a 24-hour notice of a cancellation, you will be charged the full session fee for all late cancellations and missed appointments.

If you are unable to keep your appointment, please notify us as soon as possible. 24 hours advance notice is preferred and 24 hours advance notice is required to avoid charges. We understand that extenuating circumstances may prevent you from providing 24 hours advance notice, and we will evaluate these situations on a case to case basis.

I have read the above fee agreement carefully and agree to its terms and conditions.

Signature

Date

FUNCTIONAL ASSESSMENT INTAKE

Occupation

Check the corresponding box(es) if you've had any of the following:

If you selected "Other" please explain:

List any significant hospitalizations and/or surgical procedures, reasons, and dates:

Do you have any skin or medication allergies?

Is there a chance you may be pregnant at this time?

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?

How much caffeine 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 provide a brief history of your illness, symptoms or reasons for which you are seeking treatment, including when symptoms began:

If you have pain is the pain constant or intermittent?

INTERMITTENTCONSTANT

Does the pain radiate?

What makes the pain better?

What makes the pain worse?

Please rate the pain intensity on a scale of 0 to 10 (10 being the worst pain)

Please indicate the symptoms you are currently experiencing by drawing on this diagram. You may also describe them below

Feel free to describe the symptoms here as well:

In general, your lifestyle is:

If you selected "Other" please explain:

Do you engage in regular exercise?

What type of exercise?

Do you have discomfort, shortness of breath, or pain with exercise?

Do you presently see an healthcare provider for your current condition?

Do you presently seek treatment from any other type of healthcare provider for the above?

(chiropractor, acupuncturist, massage therapist, etc)

Have you had any prior experience with myofascial release therapeutic touch?

(chiropractor, acupuncturist, massage therapist, etc)

BY SIGNING BELOW, I HEREBY ACKNOWLEDGE THAT I UNDERSTAND THE TREATMENT PLAN OUTLINED AND EXPLAINED TO ME BY THE NURSE PRACTITIONER AND I CONSENT TO THE TREATMENT.