Pre-appointment Screening Form

Name

Email Address

Choose the appointment type: Choose the appointment type: Online At the Clinic

Phone number

Date of Birth DD/MM/YY

Home address

1. Please describe the problems that you are having with your pelvic floor?

2. How long have you had these problems?

3. Do you wear a pad ? If so how many per day?

4. Do you have bladder leakage? 4. Do you have bladder leakage? Yes No

5. Do you have bladder leakage with coughing or sneezing? 5. Do you have bladder leakage with coughing or sneezing? Yes No

6. Do you have bladder leakage with the urge to empty your bladder? 6. Do you have bladder leakage with the urge to empty your bladder? Yes No

7. How many times a day do you empty your bladder?

8. How many times do you empty your bladder at night?

9. Do you sometimes have leakage from the bowel? 9. Do you sometimes have leakage from the bowel? Yes No

10. Do you sometimes leak gas from your bowel? 10. Do you sometimes leak gas from your bowel? Yes No

11. Do you sometimes feel as it you haven’t completely emptied your bowel? 11. Do you sometimes feel as it you haven’t completely emptied your bowel? Yes No

12. Do you ever feel as if your pelvic organs, your bladder, bowel or womb are coming down? 12. Do you ever feel as if your pelvic organs, your bladder, bowel or womb are coming down? Yes No

13. (If applicable) Have you had children? If yes, how many?

14. (If applicable) Did you have a forceps delivery? 14. (If applicable) Did you have a forceps delivery? Yes No Not applicable

15. What operations have you had?

16. What medications are you taking?

17. Do you have epilepsy? 17. Do you have epilepsy? Yes No

18. Do you have a heart condition? If so what is it called?

19. If you would like to add anything else, including other diagnosed health conditions or questions, please write below?