Men’s Health Physiotherapy

Men’s Health Physiotherapy

Patient Consent Form
Thank you for choosing to attend a Men’s Health Physiotherapy appointment with Complete Physio. Please complete the personal details below and read the information before signing to confirm your understanding and consent.
Personal Details
Name*

PrefixFirst NameLast Name
Date of Birth*

DayMonthYear
Address

Street Address

Street Address Line 2

CityCounty

Post Code
* Please enter either a landline or mobile number below. This is required if we need to contact you about the information you provide on this form. Your private data will not be shared with any third party.
Mobile Number*
Mobile phone number
Landline Number (unnecessary if mobile number provided)

Area CodePhone Number
Email*
example@example.com
Next of Kin
Name*

PrefixFirst NameLast Name
Phone Number*
Biological Sex (for clinical relevance) - What is your biological sex (as assigned at birth)?

MaleFemaleIntersexPrefer not to say
Gender Identity - "What is your current gender identity?"

ManWomanNon-binaryTrans manTrans womanPrefer not to sayOther
Pronouns - "What pronouns do you use?"

He/HimShe/HerThey/ThemPrefer not to sayOther
Health Administration
Referrer (if applicable)
Do you have private health insurance?

YesNo
If yes, please state provider:
Provider
and authorisation code:
Authorisation code
Are you referring yourself or have you been recommended by GP or medical consultant?

SelfG.P.Medical Consultant
What is your main concern or reason for attending?
Have you had surgery or medical treatment in relation to this problem – please provide details below:
Past medical history
Current medications taken
What to Expect During Your Appointment
The following is designed to allow a thorough and holistic assessment so your therapist can develop a personalised treatment plan, based on your goals and agreed next steps.

Please tick each checkbox below to confirm that you provide consent.
Your Men’s Health Physiotherapy session will typically involve:*

A detailed conversation to explore your medical history, current concerns, lifestyle factors, and goals.A physical assessment, which may involve checking your breathing, posture, movement, abdominal and pelvic muscle function using external techniques.Treatment, which may include education, tailored exercises, breathing techniques, manual therapy, and pelvic floor muscle training.
Common Conditions Treated in Men’s Health Physiotherapy Include:
- Urinary leakage (incontinence)
- Erectile difficulties or changes in sexual function
- Pelvic floor dysfunction (weak or overactive muscles)
- Pelvic pain or discomfort
- Nerve-related pain in the pelvic region (e.g. pudendal nerve sensitivity)
- Painful urination
- Urine leakage at orgasm (climacturia)
- Difficulty getting or maintaining a firm erection (hard-flaccid syndrome)
- Before and after prostate surgery (e.g. prostatectomy rehab)
- Bowel issues, including faecal incontinence or constipation
- Changes in penile shape or discomfort due to scar tissue (e.g. Peyronie’s disease)
- Groin or pubic joint pain (osteitis pubis)
Your Comfort and Privacy
- You will remain fully dressed throughout the session, though we may ask you to adjust your clothing slightly to allow for observation of posture, breathing, or pelvic position.
- No internal (rectal) examinations will be performed.
- You are welcome to bring a chaperone with you if you feel more comfortable.
- You can withdraw consent or pause the session at any time.
Consent Declaration

I confirm that I have read and understood the information above. I consent to take part in the Men’s Health Physiotherapy assessment and treatment as outlined, and I understand that I can ask questions or withdraw at any time.
Date*

DayMonthYear
Date
To draw your signature: Place the mouse cursor in the area below, click and hold the left mouse button then move the mouse as if you were drawing.*
Should be Empty:

Personal Details

Next of Kin

Health Administration

What to Expect During Your Appointment