Pelvic Floor Therapy Evaluation

Intake and evaluation form for documenting pelvic floor symptoms, functional impact, muscle assessment, and treatment goals to establish a baseline for pelvic health intervention.

Patient and Visit Information

• Patient name
• Date of birth
  Optional unless needed to match the chart or confirm identity.
• Evaluation date
• Referring provider
• Primary reason for visit
  Briefly describe the main pelvic health concern in the patient's own words.

Consent, Disclosure, and Privacy

• Consent to document health information
  I consent to the collection and documentation of health information needed for my pelvic floor therapy evaluation and treatment planning.
• Acknowledge sensitive questions
  I understand this form may ask about bowel, bladder, sexual, obstetric, and other intimate health topics that are relevant to pelvic health care.
• Preferred terms, boundaries, or accommodations
  Share any communication preferences, cultural considerations, or ADA reasonable-accommodation needs for the evaluation.

Pelvic Health Symptoms

• Which symptoms are you experiencing?
• Other symptoms
• When did these symptoms begin?
• How often do symptoms occur?
• Symptom severity
• Triggers or aggravating factors
  Examples: coughing, lifting, exercise, prolonged sitting, bowel movements, or stress.

Relevant History

• Pregnancy or postpartum history relevant to this visit
  Include pregnancy status, delivery type, postpartum timing, or complications if relevant.
• Prior pelvic surgeries or procedures
• Relevant medical conditions
• Current medications or treatments related to symptoms

Functional Impact

• Activities affected by symptoms
• Describe functional limitations
• Current activity restrictions or self-limits

Pelvic Floor Assessment Findings

• External observation findings
  Include posture, breathing strategy, tissue appearance, guarding, or other relevant observations.
• Pelvic floor muscle tone
• Pelvic floor muscle strength
• Coordination and relaxation
• Pain with assessment
• Pain details

Clinical Impression, Goals, and Plan

• Clinical impression
• Patient goals
• Recommended treatment frequency
• Plan of care summary