Emsella Pre-Screening Form
Your Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Day
-
Month
Year
Date
Which best describes your pelvic anatomy for treatment purposes?
*
Male
Female
Health History
Are you currently pregnant or trying to become pregnant?
*
YES
NO
Have you been diagnosed with a pelvic floor disorder or urinary/faecal incontinence or constipation?
*
YES
NO
Please provide details
Do you experience urine leakage when coughing, sneezing, laughing, or exercising?
*
YES
NO
Please provide details
Do you experience urgency or frequent trips to the bathroom, including at night?
*
YES
NO
Please provide details
Have you given birth (vaginal or caesarean)?
*
YES
NO
Please provide details (include date of your births)
Do you have a history of pelvic pain or conditions like interstitial cystitis?
*
YES
NO
Please provide details
Have you been diagnosed with any neurological disorders (e.g. epilepsy, multiple sclerosis)?
*
YES
NO
Please provide details
Do you experience any uncontrolled bleeding or clotting disorders?
*
YES
NO
Please provide details
Are you currently undergoing treatment for cancer or have a history of cancer?
*
YES
NO
Please provide details
Are you currently taking any medications? (e.g. anticoagulants, muscle relaxants, etc.)
*
YES
NO
Please provide details
Do you have any diagnosed heart conditions or use a pacemaker or defibrillator?
*
YES
NO
Please provide details
Have you tried any forms of therapy to assist your current or previous concerns? (kegal exercises, pelvic floor physiotherapy, medication, surgery, etc?)
*
YES
NO
Please provide details
Have you experienced trouble with sexual satisfaction or sensation?
*
YES
NO
Please provide details
Have you experienced pelvic organ prolapse?
*
YES
NO
Please provide details
Do you have any untreated open wounds or skin infections in the pelvic area?
*
YES
NO
Please provide details
Do you have a copper IUD, vaginal ring, or any contraceptive implant?
*
YES
NO
Please provide details
Do you have any metal implants in or near the pelvic area?
*
YES
NO
Please provide details
Do you have osteoporosis or bone density concerns?
*
YES
NO
Please provide details
Goals for Treatment
What outcomes are you hoping to achieve with Emsella? (Tick all that apply)
*
Improved bladder control
Fewer nighttime bathroom trips
Support after childbirth
Increased intimate wellbeing
Stronger pelvic floor
Other
Consent & Acknowledgement
Consent & Acknowledgement
*
I confirm that the information I have provided is true and complete to the best of my knowledge.
I have disclosed all medical conditions, medications, and potential contraindications.
I understand that results may vary and that this treatment is not a substitute for medical care.
I have been given the opportunity to ask questions and understand how the Emsella treatment works.
I consent to undergo the Emsella consult and treatment plan as recommended by my practitioner.
I understand I should inform my practitioner of any health changes before each session.
Submit
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