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Montgomery PFC Center

Name

DOB *

YYYY

Please describe your main problem *

When did it begin? *

Is it getting better, worse, or staying the same? *

Which of the following best describes how your injury occurred *

Childbirth

After surgery

A fall

Lifting

Degenerative process

During recreations / sports

Car accident

Trauma

Running

Unknown

Other:

Date of last pelvic examination

YYYY

Date of last urinalysis

YYYY

Have you had any previous treatments for this condition? If yes, please describe *

Incontinence

How long have you had leaking problems? months/years

How many times do you leak during the daytime?

How many times do you leak during the night time?

Severity of leakage

Do you leak if you: (check all that apply)

Cough

Sneeze

Lift heavy objects

Laugh

Run

Jump

Cry

Have intercourse

Shower

Hear water running

Opening the front door

Other:

What makes it worse?

Do you use any protection against leaks?

If yes, how many pads do you use during the day?

If yes, how many pads do you use during the night?

Do you have trouble getting to the bathroom on time?

Toileting

Frequency of urination daytime?

Frequency of urination night time?

After starting to urinate, can you completely stop urine flow?

Do you have trouble initiating a urine stream?

Do you have problems with constipation or diarrhea?

Do you feel unable to empty bladder fully?

Do you have pain with a full bladder?

Do you have a strong urge to urinate?

Bowel Symptoms

Strain to have a bowel movement?

Include fiber in your diet?

Take laxatives / enema regularly?

Have pain with a bowel movement?

Leak/stain feces?

Have diarrhea often?

Leak gas by accident?

Have a very strong urge to move your bowels?

How often do you move your bowels per day/week?

Most common stool consistency

liquid

soft

firm

pellets

other

Daily Fluid Intake

What is your daily fluid intake?

How many caffeinated glasses?

History

Are you currently sexually active

History of/or present sexually transmitted disease?

Type?

Do you have pain or problems during sexual activity? Any urine or fecal leakage? Please describe.

Female Only Section

Are you pregnant or attempting pregnancy?

# of Vaginal deliveries

# of Cesarean deliveries

# of Episiotomies

Date of last pap smear

YYYY

Complications of childbirth?

Did you have any complications during pregnancy? (check all that apply)

Low back pain

Leaking

Stress

Urge

Did you have any complications after your pregnancy? (check all that apply)

Diastatis Recti

Leaking

Low back pain

Have you had a hysterectomy?

Do you ever have a falling out feeling? (check all that apply)

Never

Pressure at the end of the day

Pressure with standing

Occasionally/with menses

Pressure with straining

Perineal pressure all day

Pain

Do you have pain with tampon use?

Do you have pain with: (check all that apply)

Sexual intercourse

Pelvic exam

Physical activity

Back, leg, groin, abdominal pain

General

What is your stress level?

Attitude toward this problem

Confidence in controlling your problem

Have you ever been taught or presecribed pelvic floor/Kegel exercises?

Any comments or concerns not asked?

Thank you!

Blue Ash Center
Chancellor Center
Dry Ridge Center
Florence Center
Hamilton Center
Independence Center
Maineville/South Lebanon
Mason Center

Montgomery Center
Oakley Center
Oxford Center
West Chester

Pelvic History Information

Montgomery PFC Center

513.701.6100