• Ashewell Emsella Pelvic Assessment

    This secure assessment helps Dr. Carly Brown determine whether a physician consultation about Emsella may be appropriate. It is a screening and treatment-planning tool, not a diagnosis or guarantee of treatment. If you believe you have a medical emergency, do not use this form; call 911 or seek immediate medical care.

  • Page 1: Initial Screening

  • Are you 18 years of age or older?*

  • Safety Screening

  • Are you currently pregnant or is there a possibility that you may be pregnant?*
  • Do you have an implanted electronic device, such as a pacemaker, defibrillator, neurostimulator, drug pump or another electronic implant?*
  • Do you have any implanted metal or surgical hardware, such as a hip or knee replacement, spinal cage, plate, screws, rods or a copper IUD?*

  • A "YES" answer does not automatically exclude you. Dr. Brown will review the type and location during your consultation.

  • Have you been told by a healthcare professional that you have severe pelvic organ prolapse?*

  • Page 2: Contact Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Preferred Contact Method*

  • Page 3: Urinary Symptoms

  • Please answer the following questions based on how you have been, on average, during the past four weeks.
  • For treatment-planning purposes, what was your sex assigned at birth?
  • How often have you leaked urine?*
  • How much urine do you usually leak?*
  • Overall, how much does urine leakage interfere with your everyday life?*
  • When does urine leakage occur? Select all that apply.*

  • Adapted from the ICIQ-UI Short Form. Copyright © ICIQ Group.

  • Page 4: Other Concerns

  • These selections help Dr. Brown prepare for your consultation. They do not determine whether Emsella is appropriate for you.

  • What else would you like to discuss during your consultation? Select all that apply.

  • Page 5: Review and Submit

  • Additional medical review recommended

    Based on your safety-screening responses, we cannot recommend Emsella through this online assessment. Please consult your physician or an appropriate specialist for individualized recommendations. This result is a preliminary screening response and is not a diagnosis.

  • Score 0 — No urinary leakage reported

    Based on your responses, you did not report current urinary leakage. Emsella would not be recommended for urinary incontinence based on this score alone. If you have other pelvic-floor concerns, you may still request a physician consultation.

  • Score 1–5 — Slight symptoms

    Your responses indicate slight urinary symptoms. A brief consultation can help determine whether observation, pelvic-floor exercises, pelvic-floor physical therapy or Emsella is appropriate for your goals.

  • Score 6–12 — Moderate symptoms

    Your responses indicate moderate urinary symptoms. A physician consultation is appropriate to review your symptom pattern and determine whether an individualized Emsella series or another treatment approach is appropriate.

  • Score 13–18 — Severe symptoms

    Your responses indicate severe urinary symptoms. We recommend physician evaluation before selecting a treatment plan. Emsella may be appropriate as part of an individualized pelvic-health approach, but this score alone does not determine the number of sessions needed.

  • Score 19–21 — Very severe symptoms

    Your responses indicate very severe urinary symptoms. We recommend physician evaluation before treatment planning to assess possible contributing conditions and determine whether Emsella, pelvic-floor physical therapy, specialist evaluation or combined care is most appropriate.

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