+353 (0) 87 2863013

IPPM Pre-appointment Form

Fill out the form to Book an Appointment

Please fill out the form below and we will get back to you to arrange the date and confirm your appointment.

Aoife Ni Eochaidh

Chartered Physiotherapist
Clinical Specialist Physiotherapist
International Pelvic Physiotherapy Management Limited

Pre-appointment Screening Form

Choose the appointment type:

4. Do you have bladder leakage?

5. Do you have bladder leakage with coughing or sneezing?

6. Do you have bladder leakage with the urge to empty your bladder?

9. Do you sometimes have leakage from the bowel?

10. Do you sometimes leak gas from your bowel?

11. Do you sometimes feel as it you haven’t completely emptied your bowel?

12. Do you ever feel as if your pelvic organs, your bladder, bowel or womb are coming down?

14. (If applicable) Did you have a forceps delivery?

17. Do you have epilepsy?

10 + 9 =

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