Women's Pelvic Health

Intake questionnaire.

Please take around 5 minutes to complete this form before your first pelvic health appointment. Your answers help your physiotherapist arrive prepared so your appointment time is focused on assessment and treatment.

Your information is kept strictly confidential and used only to guide your clinical care.

About you

First name *

Last name *

Date of birth *

Email address

Occupation

Your visit

What are your main reasons for coming to see a pelvic floor physiotherapist? *

What do you hope to get out of your physiotherapy session today?

Medical history

Please list any medical conditions you have

e.g. endometriosis, diabetes, hypertension, autoimmune conditions — or write "None"

Please provide details of any previous surgeries

Do you do any regular exercise, and if so what sort?

Please list any regular medications you take

Please include any contraception medication or device

Obstetric history

Have you ever been pregnant? *

How many children have you given birth to?

How did you give birth?

Select all that apply

Did you have any tears or require forceps and/or vacuum assistance?

Select all that apply

Pelvic floor questionnaire

For each symptom, indicate whether you experience it and, if yes, how much it bothers you.

1. Do you experience urine leakage (incontinence) related to physical activity, such as coughing, sneezing, laughing, lifting or changing position?

How much does it bother you?

2. Do you experience frequent urination (needing to urinate more than usual, including the need to get up two or more times during the night because of a need to urinate)?

How much does it bother you?

3. Do you experience an abnormally strong feeling of urgency to urinate (sudden, compelling urge to urinate)?

How much does it bother you?

4. Do you experience urine leakage associated with a feeling of urgency (involuntary loss of urine occurring while suddenly having a strong urge to urinate)?

How much does it bother you?

5. Do you experience difficulty or discomfort passing urine?

How much does it bother you?

Pelvic floor questionnaire

Continued — bowel, prolapse and sexual function.

6. Do you experience the feeling of a bulge in the vagina (either the bladder, uterus, vagina or rectum)?

How much does it bother you?

7. Do you experience difficulty opening your bowels, such as straining?

How much does it bother you?

8. Do you experience accidental leakage of faecal matter or gas?

How much does it bother you?

9. Are you sexually active?

Does pain or discomfort curtail your ability to enjoy sex?

Questionnaire received.

Your answers have been saved to your clinical file. Your physiotherapist will review them before your appointment so they arrive prepared.

If you haven't already booked, you can do so online or call us on (02) 4721 5567.

Book an appointment →