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Run: Pelvic Floor Therapy Evaluation

Pelvic Floor Therapy Evaluation template for documenting symptoms, history, exam findings, and treatment goals in one structured intake. Use it to establish ...

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Patient and Visit Information

Patient name (required)

Date of birth

Optional unless needed to match the chart or confirm identity.

Evaluation date (required)

Referring provider

Primary reason for visit (required)

Briefly describe the main pelvic health concern in the patient's own words.

Consent, Disclosure, and Privacy

Consent to document health information (required)

I consent to the collection and documentation of health information needed for my pelvic floor therapy evaluation and treatment planning.

Yes No N/A

Acknowledge sensitive questions (required)

I understand this form may ask about bowel, bladder, sexual, obstetric, and other intimate health topics that are relevant to pelvic health care.

Yes No N/A

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? (required)

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 (required)

Describe functional limitations (required)

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 (required)

Patient goals (required)

Recommended treatment frequency

Plan of care summary

Get your results

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Email (required)

Your name (optional)

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