Women's Health Physitherapy Consult Form

General & Women's Health Physiotherapy Form

Address

GP Name & Address:*

Please outline GP details and note whether they, or another health care practitioner, recommended that you attend Physio&Wellness Clinic

CURRENT HEALTH REPORT

Reason for attending physiotherapy treatment Please take time to outline why you have arranged to attend Physio & Wellness Clinic for a physiotherapy assessment. What is your main complaint? When did it start? Please outline any past medical history pertinent to your presenting condition. You will get more from your consultation if you spend time giving this question some thought and providing specific information

What is your complaint and your long term goals in attending this clinic?

Is your condition interfering with your:

Work

Sleep

Daily Routine

Other (explain)

What activities aggravate your condition?

What makes you feel better?

EXERCISE/HABITS OF DAILY LIVING

Please provide information relating to duration and intensity. Class or gym workout? If walking or cycling etc, please note the terrain. If you are NOT currently exercising, please note N/A.

What meaningful activity do you want to do but can't do now?

GENERAL HEALTH HISTORY

List any major accidents, serious falls or injuries (with dates)

List Surgeries/Hospital Stays (dates)

List X-rays or special imaging taken in the last 10 years and their dates:

List of Current Medication*

Please list all current medications, including dosage taken. If not taking any medication, mark not applicable.

Obstetric History (mark not applicable where appropriate)

Obstetric History is important when assessing bowel/bladder/sexual function issues. It is also important when assessing any orthopaedic conditions such as spinal/pelvic/hip pain and when conducting a pregnancy or post natal screening assessment. This is because the pelvic floor, abdominal, spinal and diaphragmatic muscles are all involved in how well your 'core' functions. Please outline information relating to delivery/deliveries e.g. c-section or vaginal delivery, weight of baby, year of birth, any obstetric injury (tears) or episiotomy, any post partum complications. Any history of miscarriage.

Gynaecological History

Please note any information that you feel may be pertinent to your current condition e.g. pelvic organ prolapse or other investigations/procedures. Last PAP Smear and Results.

PELVIC FLOOR SCREENING

The following section will ask you questions relating to your bladder, bowel and sexual function. We ask these questions as it is important for us to screen the pelvic floor. The reason for this is that the pelvic floor forms an integral part of your 'core' muscle function. Some bladder and bowel issues can suggest that the pelvic floor is potentially weak, over-active or injured. If this is the case, it can influence back pain/function as well as general hip and lower limb function. If you do NOT feel comfortable answering any of these questions, please simply leave blank:

BLADDER

Please use this box if there is any other information you would like to share with your clinician prior to your appointment:

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Thank you for taking the time to complete this form! We really appreciate the time that you put in to completing this form. The information provided will very much help your clinican during your initial consultation. We rely on your feedback to help us improve our services. Your input is greatly appreciated.

info@physiowellnesshub.ie

+353-851-372002