CLIENT INTAKE FORM

Client Details

Title *

Sex *

Gender *

First name *

Surname *

Preferred name *

Date of Birth *

Occupation

Email Address *

Mobile *

Home Phone

Address *

Suburb *

State *

Post Code *

Emergency Contact

Next of Kin *

Relationship *

Contact number *

Referrer Information

GP Name

GP Clinic

Referrer name

Referrer clinic

Have you seen a Pelvic Health Physio before?

If yes, what was their name or clinic?

Privacy Statement

As part of your medical appointment your personal information and Records may be collected by your clinician, used and disclosed, including, but not limited to the reasons following:

Communicating relevant information with your treating doctors, specialists, insurers or other allied health professionals
Use by other pelvic physiotherapists involved in your care, when consulting with you
For research purposes (de-identified, meaning you are not able to be identified from information provided)

If you have any concerns or wish to restrict access to your personal health information, please discuss these with your treating physiotherapist.

ALL PATIENTS TO READ AND SIGN

DECLARATION: I understand and agree that:

1. If I am unable to attend my appointment I will give 24 HOURS notice of my cancellation. If I do not cancel with notice I will be charged a Non-Attendance Fee of $55 for my missed appointment.

2. I am required to pay on the day for all consultations. Hug Pelvic Physiotherapy accepts only EFTPOS and bank transfer payments. I will be eligible for a private health rebate with ancillary physiotherapy cover, claimable online or at the private health branch.

3. In the event that my accounts are outstanding longer than 45 days, I will be responsible for all collection fees incurred.

4. For insurance claims, I will be personally responsible for payment of all accounts incurred by me in the event that liability is denied, or placed in dispute by the insurance company.

5. I consent to treatment provided by the physiotherapist.

Signature *

Draw signature|Type signatureClear

Date *

Appointment Preparation

Reason for your visit *

Briefly describe your symptoms. *

What goals would you like to achieve from attending pelvic physiotherapy? *

GENERAL HEALTH

Medical screen - please tick and provide details if appropriate:

If others, please specify

In you have any Neurological medical conditions or mood disorders, please provide details:

If any urinary tract infections, please give more information on the last UTI and the frequency in the last 12 months:

Medication(s):

Surgery/Medical procedures:

Any other surgery/procedures not listed:

Current Exercise: *

YesNo

Any other exercise not listed:

Frequency of exercise:

Hormonal Status:

Systemic Hormone Replacement TherapyOral Contraceptive PillTopical Cream (Ovestin, Vagifem or other)

Number of Pregnancies: (G)

Number of Deliveries: (P)

Type of deliveries: (c-section / vaginal) (scheduled or emergency / spontaneous or induced)

Bladder Control Questionnaire (ICIQ-SF):

Please answer the following questions, thinking about how you have been, on average, over the past 4 weeks:

How often do you leak urine? *

How much urine do you leak? *

When does urine leak? *

never - urine does not leakleaks before you can get to the toiletleaks when you cough or sneezeleaks when you are asleepleaks when you are physically active/exercisingleaks when you have finished urinating and are dressedleaks for no obvious reasonleaks all the time

If you are pre/post surgery or pregnant/post-partum you may finish here. Scroll to the bottom to submit.

If not please know, I aim to provide holistic care.

Please continue if you have pelvic symptoms. These are very useful tools for capturing the many aspects of life that may be contributing.

Every question is important to answer.

Thank you.

Central Sensitisation Inventory (CSI)

Have you been diagnosed by a doctor with any of the following disorders? Tick undiagnosed if it is suspected.

Please select the best response for each statement:

CSI Total

Categorisation (office use only)

The Pelvic Health Psychological Screening Questionnaire (3PSQ)

PART A: In the past MONTH...

Part A total:

Part B: During my life...

I recall a stressful or traumatic life event that has had a negative impact on me (T)

PART C: If you have been sexually active in the past month, please answer the following questions:

If you DO NOT have a pain issue, you have completed the form and can scroll to the end to SUBMIT.

If the program will not allow you to submit, please ensure you have answered all the questions marked with an asterick ( * ) .

I look forward to meeting you, listening to your story, engaging in recovery and epowering you for the future.

If you have pain please complete the following 2 short questionnaires. These help me to understand how impacting the pain is on your daily life.

Pelvic Pain Impact Questionnaire (PPIQ)

For each of the following 8 questions, how much your pelvic pain has affected these aspects of your life during the past month.

In the past month, how much has your pelvic pain affected your:

PPIQ total:

Fremantle Perineal Awareness Questionnaire (Fre-PAQ)

The perineum is the area of skin located between your front passage and back passage (anus), this is the area that touches the gusset of your underwear. There are muscles behind this skin, these are the pelvic floor muscles.

Fre-PAQ total:

Save and Complete Later