Pelvic Floor Therapy Intake Form
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Pelvic Floor Therapy Intake Form
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The Pelvic Floor Therapy Intake Form is designed specifically for pelvic floor physical therapists, pelvic rehabilitation specialists, and women's health PT practices that evaluate and treat conditions including urinary incontinence, pelvic organ prolapse, pelvic pain, bowel dysfunction, diastasis recti, and sexual dysfunction. This pelvic floor PT intake form captures the sensitive and detailed clinical history that pelvic health providers need to develop an individualized treatment plan, presented in a patient-friendly format that helps people feel comfortable sharing information about symptoms they may find difficult to discuss.
This pelvic rehabilitation intake form includes comprehensive symptom questionnaires covering bladder function (urgency, frequency, stress incontinence, urge incontinence, nocturia, incomplete emptying), bowel function (constipation, fecal incontinence, straining, incomplete evacuation), and pain assessment (location, intensity, triggers, duration, character). The obstetric history section captures pregnancy count, delivery methods (vaginal, cesarean, assisted), perineal tears or episiotomy, birth weights, and postpartum recovery complications. Surgical history focuses on pelvic and abdominal procedures including hysterectomy, prolapse repair, cesarean sections, laparoscopy, and hernia repair. A sexual health section addresses pain with intercourse, arousal difficulties, and any history of pelvic trauma, all presented with sensitivity and clear privacy assurances.
Built for the pelvic floor therapy workflow, this template collects current medications that may affect pelvic floor function (anticholinergics, muscle relaxants, hormone therapy, stool softeners), insurance information for billing and prior authorization, and a treatment consent that specifically addresses the internal and external assessment techniques used in pelvic floor physical therapy. Patients can complete the form privately on their own device before the initial evaluation, giving the therapist time to review the history and prepare a focused, efficient first session that maximizes treatment time and minimizes the need to repeat sensitive questions in person.
What's included
- Patient demographics and referring provider information
- Bladder and urinary symptom questionnaire
- Bowel function and constipation assessment
- Pain location, intensity, and trigger documentation
- Obstetric history with delivery details and complications
- Pelvic and abdominal surgical history
- Current medication list with pelvic-relevant drug screening
- Insurance information for billing and prior authorization
- Pelvic floor therapy-specific treatment consent with e-signature
- Medical conditions checklist
Who uses this template
- Pelvic floor physical therapy and pelvic rehabilitation clinics
- Women's health physical therapy practices
- Urogynecology and continence therapy centers
- Postpartum recovery and diastasis recti rehabilitation programs
All form fields
15 fields across 3 pages. Customize any field after signing up.
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