Live Well Waterford

Personal and professional, physiotherapist-led classes and treatments for both you and your baby

General Physiotherapy Screening

General Physiotherapy Screening Evaluation

To be completed by all clients attending for general physiotherapy assessment.

Session
Client Name:*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mobile Telephone Number:*
Email Address:*
Date of Birth*
GP Name & Address:*
Please outline GP details and note whether they, or another health care practitioner, recommended that you attend Live Well Waterford Clinic.
CURRENT HEALTH REPORT
Reason for attending for physiotherapy treatment
Please take time to outline why you have arranged to attend Live Well Waterford 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*
What are your long term goals in attending this clinic?*
Is your condition getting worse?*
- No
- Yes
- Static
Is your condition interfering with your:*
- Work
- Sleep
- Daily Routine
- Other (explain)
If other, please explain:
What activities aggravate your condition?*
What makes you feel better?*
Have you had this or a similar condition before?*
Are your present complaints due to injury?*
If yes, please explain:
Have you had previous physiotherapy?*
If yes, please explain:
Have you seen other physicians for this condition?*
If yes, please explain:
EXERCISE/HABITS OF DAILY LIVING
What is your current exercise level?*
- Please Select....
- None
- Moderate
- Heavy
Please use the box below to outline any exercise that you do.
Please provide information relating to duration and intensity. Class or gym workout? If walking or cycling etc, please note the terrain. If you are NOT currently exercising, please note N/A.
Work Activity*
- Sitting
- Standing
- Walking
- Light Labour
- Heavy Labour
- Not currently working
Stress Level:*
- High
- Moderate
- Low
Do you do any stress reduction or relaxation activities?*
Are you currently on psychotropic medication or receiving psychological counselling?*
What meaningful activity do you want to do but can't do now?*
Do you smoke?*
If yes, how much per day?
GENERAL HEALTH HISTORY
List any major accidents, serious falls or injuries (with dates):*
List Surgeries/Hospital Stays (dates)*
List X-rays or special imaging taken in the last 10 years and their dates:*
List of Current Medication*
Please list all current medications, including dosage taken. If not taking any medication, mark not applicable.
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.
Gynaecological History:*
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:
Bladder
How many times do you pass urine in a day?
- Up to 7
- between 8 - 10
- between 11 - 15
- more than 15
How many times do you get up at night to pass urine?
- 0 - 1
- 2
- 3
- More than 3 times
Do you need to hurry or rush to pass urine when you get the urge?
- can hold on
- occasionally (< 1/week)
- frequently (1+/wk)
- daily
Does urine leak when you rush or hurry to the toilet or can't make it in time?
- not at all
- occasionally (< 1/week)
- frequently (1+/wk)
- daily
Do you leak urine with coughing, sneezing, laughing or exercising?
- not at all
- occasionally (< 1/week)
- frequently (1+/wk)
- daily
Is your urine stream (urine flow) weak, prolonged, or slow?
- never
- occasionally (< 1/week)
- frequently (1+/wk)
- daily
Do you have a feeling of incomplete bladder emptying?
- never
- occasionally (< 1/week)
- frequently (1+/wk)
- daily
Do you need to strain to empty your bladder?
- never
- occasionally (< 1/week)
- frequently (1+/wk)
- daily
Do you have to wear pads because of urinary leakage?
- none - never
- as a precaution
- when exercising/during the cold
- daily
Do you limit your fluid intake to decrease urinary leakage?
- never
- before going out
- moderately
- always
Do you have frequent bladder infections?
- no
- 1-3 /year
- 4-12 /year
- > 1/month
Do you have pain in your bladder or urethra when you empty your bladder?
- never
- occasionally (< 1/week)
- frequently (1+/wk)
- daily
Does the urine leakage affect your routine activities like recreation, socialising, sleeping, shopping etc?
- Not at all
- slightly
- moderately
- greatly
- not applicable
How much does your bladder problem bother you?
- Not applicable (I don't have problems)
- Not at all
- Slightly
- Moderatly
- Greatly
Bowel Function
How often do you usually empty your bowels?
- Every other day
- <3 days/ week
- <1 / week
- >1 / week
How is the consistency of your usual stool?
- soft
- firm
- hard/pebbles
- watery
- variable
Do you have to strain a lot to empty your bowels?
- never
- occasionally (< 1/week)
- frequently (1+/wk)
- daily
Do you use laxatives to empty your bowels?
- never
- occasionally (< 1/week)
- frequently (1+/wk)
- daily
Do you feel constipated?
- never
- occasionally (< 1/week)
- frequently (1+/wk)
- daily
When you get wind or flatus, can you control it or does wind leak?
- never
- occasionally (< 1/week)
- frequently (1+/wk)
- daily
Do you get an overwhelming sense of urgency to empty your bowels?
- never
- occasionally (< 1/week)
- frequently (1+/wk)
- daily
Do you leak watery stool when you don't mean to?
- never
- occasionally (< 1/week)
- frequently (1+/wk)
- daily
Do you have a feeling of incomplete bowel emptying?
- never
- occasionally (< 1/week)
- frequently (1+/wk)
- daily
Do you have to use finger pressure to help empty your bowels?
- never
- occasionally (< 1/week)
- frequently (1+/wk)
- daily
How much does your bowel problem bother you?
- Not applicable (I don't have problems)
- Not at all
- Slightly
- Moderately
- Greatly
Prolapse Symptoms
Do you have a sensation of tissue protrusion or a lump or bulging in your vagina?
- never
- occasionally (< 1/week)
- frequently (1+/wk)
- daily
Do you experience vaginal pressure or heaviness or a dragging sensation?
- never
- occasionally (< 1/week)
- frequently (1+/wk)
- daily
Do you have to push back your prolapse in order to void?
- never
- occasionally (< 1/week)
- frequently (1+/wk)
- daily
- not applicable
Do you have to push back your prolapse to empty your bowels?
- never
- occasionally (< 1/week)
- frequently (1+/wk)
- daily
- not applicable
How much does your prolapse bother you?
- Not applicable (I don't have problems)
- Not at all
- Slightly
- Moderately
- Greatly
Sexual Function
Are you sexually active?
- Yes
- No
Do you experience pain during sexual intercourse?
- never
- occassionally
- frequently
- always
Do you leak urine during sexual intercourse?
- never
- occassionally
- frequently
- always
How much do these sexual issues bother you?
- Not applicable (I don't have problems)
- Not at all
- Slightly
- Moderately
- Greatly
Please use this box if there is any other information you would like to share with your clinician prior to your appointment:
If you have no further information, please mark not applicable.
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.

Live Well Waterford

General Physiotherapy Screening

General Physiotherapy Screening Evaluation

CURRENT HEALTH REPORT

EXERCISE/HABITS OF DAILY LIVING

GENERAL HEALTH HISTORY

PELVIC FLOOR SCREENING

Bladder

Bowel Function

Prolapse Symptoms

Sexual Function

Thank you for taking the time to complete this form!

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