Pelvic Floor Therapy Evaluation

This template is for pelvic health physical therapists, occupational therapists, and clinicians who evaluate pelvic floor symptoms and function. It fits initial visits where you need a baseline, not a quick follow-up note. It also helps support referrals by organizing the patient’s history, symptom pattern, and assessment findings in one place.

It covers common pelvic health concerns such as urgency, leakage, pelvic pain, constipation, postpartum changes, and pain with assessment. The symptom section is broad enough to capture other complaints through an open field, while the history and functional impact sections help connect symptoms to daily activity. It is especially useful when the presentation is mixed and needs careful documentation.

Use it at the first pelvic floor therapy evaluation and again only when a new episode of care requires a fresh baseline. It is not meant for every treatment session. If the patient’s condition changes significantly, you can clone it and document a new evaluation rather than forcing the old one to do both jobs.

Include consent to document health information, acknowledgment of sensitive questions, and any preferred terms or boundaries the patient wants respected. Because pelvic health intake can involve highly personal PII and health data, the form should make clear what is collected and why. A short disclosure line also helps set expectations for how the information will be used in care.

Yes, because it collects health information and may include sensitive sexual, urinary, bowel, or pain-related details. Keep the form aligned with minimum-necessary collection, use clear field labels, and avoid asking for information that is not needed for care. If the form is public-facing, make sure accessibility and consent language are clear and easy to understand.

Common mistakes include leaving symptom onset vague, mixing current symptoms with past history, and documenting pain without noting what triggered it. Another issue is over-collecting details that are not needed for treatment planning. The best entries are specific, concise, and tied to function, assessment findings, and next steps.

Yes. You can add conditional logic for postpartum history, prior pelvic surgeries, or pain details so only relevant fields appear. That keeps the form shorter and easier to complete while still capturing the information needed for the specific visit type. It also supports progressive disclosure instead of showing every possible question at once.

An ad-hoc note is harder to compare across visits and easier to miss key details like symptom frequency, triggers, or functional limitations. This template gives you a repeatable structure, which improves consistency and makes it easier to track change over time. It also reduces the chance that important consent or boundary information gets buried in narrative text.

The patient should see a clear confirmation that the evaluation was received and that the clinician will review it before or during the visit. Internally, the submission should route into the chart or workflow with an audit trail so the assessment can be completed efficiently. If a patient reports severe pain or red-flag symptoms, the workflow should flag that for prompt review.