Patient History Form

First Name

Last Name

Age

Date of Birth

Phone

Address Line 1

Address Line 2

City

Post Code

Province

Patient History

Family Doctor

Care Card Number

Describe the current problem that brought you here:

When did your problem first begin?

Was the first episode of the problem related to a specific incident and if so please describe and specify date?

Date of specific incident:

Since that time is it:

Staying the same

Getting Better

Getting Worse

Please describe the nature of the pain (i.e. burning, ache):

Describe previous treatment/exercises you have used:

Activities or events that cause or aggravate your symptoms. Please check all that apply.

If you selected other, please describe:

What relieves your symptoms?

How has your lifestyle or quality of life been altered or changed because of this problem?

Social Activities (exclude physical activities)

Diet or food intake, specify:

Physical Activity, specify:

Work, specify:

Other, specify:

Please list your treatment goals and concerns:

Since the onset of your current symptoms have you had any of the following:

Unexplained muscle weakness

Numbness or tingling

Unexpected weight change

Dizziness or fainting

If you selected other, please specify:

Date of last Physical Exam

Tests Performed

Current Psych Therapy?

YesNo

Occupation

Hours per week that you work

Do you have any activity restrictions

Have you ever had any of the following conditions or diagnoses?

If you selected other, please describe:

If you selected Allergies, please list

Surgical Procedure History

Surgery for your bones/joints

Surgery for your female organs

Surgery for your prostate

Surgery for your brain

Surgery for your bladder

Surgery for your abdominal organs

Ob/Gyn History (females only):

Date of Menopause

Males Only:

Prostate disorders

Shy Bladder

Painful ejaculations

Pelvic/Genital pain location

Erectile dysfunction

Other, please describe below

If you selected other, please describe:

Prescription Medications

Pills, injections, patch

Reason for taking:

Date started:

Over the Counter Medications

Pills, injections, patch

Reason for taking:

Date started:

Pelvic Symptom Questionnaire Bladder, Bowel Habits, and Symptoms

Trouble holding back gas/feces

Seepage/loss of BM without awareness

Blood in stool / feces

Constipation/straining % of time

Need to support/touch to complete BM

Current Laxative use - type #

Dribbling after urination

Trouble emptying bladder fully

Urinary intermittent/ slow stream

If you selected other, please describe:

Frequency of Urination

Awake Hours

Times per day

Sleep hours

Time per night

When you have a normal urge to urinate, how long can you delay before you have to go to the toilet?

Minutes

Hours

None

The usual amount of urine passed is:

None1-2 days3-4 days5+ days

Frequency of Bowel Movements

Awake Hours

Times per day

When you have an urge to have a bowel movement, how long can you delay before you have to go to the toilet?

Minutes

Hours

None

If constipation is present describe management techniques

Fluid Intake

Average daily fluid intake (8 oz or one cup)

Of the total how many caffeinated?

Rate a feeling of organ "falling out" / prolapse or pelvic heaviness / pressure:

None present

Times per month (specify if related to activity or your menstrual period):

With standing

With exertion or straining:

Bladder Leakage (Number of Episodes)

None

Moderate protection (absorbent product, maxi pad)

Only with physical exertion/cough

Times per week

Times per month

Bowel Leakage (Number of Episodes)

None

Only with exertion/strong use

Times per day

Times per week

Times per month

On average, how much urine do you leak?

None

Just a few drops

Wets underwear

Wets the floor

Other

On average, how much stool do you leak?

None

Stool staining

Small amount in underwear

Complete emptying

Other

What form of protection do you wear?

If other please describe

On average, how many pad or protection changes are required in a 24 hours?