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  • Emsella Pre-Screening Form

  • Your Information

  • Format: (000) 000-0000.
  • Date of Birth
     - -
  • Which best describes your pelvic anatomy for treatment purposes?*

  • Health History

  • Are you currently pregnant or trying to become pregnant?*
  • Have you been diagnosed with a pelvic floor disorder or urinary/faecal incontinence or constipation?*
  • Do you experience urine leakage when coughing, sneezing, laughing, or exercising?*
  • Do you experience urgency or frequent trips to the bathroom, including at night?*
  • Have you given birth (vaginal or caesarean)?*
  • Do you have a history of pelvic pain or conditions like interstitial cystitis?*
  • Have you been diagnosed with any neurological disorders (e.g. epilepsy, multiple sclerosis)?*
  • Do you experience any uncontrolled bleeding or clotting disorders?*
  • Are you currently undergoing treatment for cancer or have a history of cancer?*
  • Are you currently taking any medications? (e.g. anticoagulants, muscle relaxants, etc.)*
  • Do you have any diagnosed heart conditions or use a pacemaker or defibrillator?*
  • Have you tried any forms of therapy to assist your current or previous concerns? (kegal exercises, pelvic floor physiotherapy, medication, surgery, etc?)*
  • Have you experienced trouble with sexual satisfaction or sensation?*
  • Have you experienced pelvic organ prolapse?*
  • Do you have any untreated open wounds or skin infections in the pelvic area?*
  • Do you have a copper IUD, vaginal ring, or any contraceptive implant?*
  • Do you have any metal implants in or near the pelvic area?*
  • Do you have osteoporosis or bone density concerns?*

  • Goals for Treatment

  • What outcomes are you hoping to achieve with Emsella? (Tick all that apply)*

  • Consent & Acknowledgement

  • Consent & Acknowledgement*
  • Should be Empty: