GP Name & Address:*
CURRENT HEALTH REPORT
Reason for attending physiotherapy treatment Please take time to outline why you have arranged to attend Physio & Wellness Clinic for a physiotherapy assessment. What is your main complaint? When did it start? Please outline any past medical history pertinent to your presenting condition. *You will get more from your consultation if you spend time giving this question some thought and providing specific information*
EXERCISE/HABITS OF DAILY LIVING
GENERAL HEALTH HISTORY
List of Current Medication*
Obstetric History (mark not applicable where appropriate)
Obstetric History is important when assessing bowel/bladder/sexual function issues. It is also important when assessing any orthopaedic conditions such as spinal/pelvic/hip pain and when conducting a pregnancy or post natal screening assessment. This is because the pelvic floor, abdominal, spinal and diaphragmatic muscles are all involved in how well your 'core' functions. Please outline information relating to delivery/deliveries e.g. c-section or vaginal delivery, weight of baby, year of birth, any obstetric injury (tears) or episiotomy, any post partum complications. Any history of miscarriage.
Please note any information that you feel may be pertinent to your current condition e.g. pelvic organ prolapse or other investigations/procedures. Last PAP Smear and Results.
PELVIC FLOOR SCREENING
The following section will ask you questions relating to your bladder, bowel and sexual function. We ask these questions as it is important for us to screen the pelvic floor. The reason for this is that the pelvic floor forms an integral part of your 'core' muscle function. Some bladder and bowel issues can suggest that the pelvic floor is potentially weak, over-active or injured. If this is the case, it can influence back pain/function as well as general hip and lower limb function. If you do NOT feel comfortable answering any of these questions, please simply leave blank:
Thank you for taking the time to complete this form! We really appreciate the time that you put in to completing this form. The information provided will very much help your clinican during your initial consultation. We rely on your feedback to help us improve our services. Your input is greatly appreciated.