By filling out this intake form, I will be able to tailor our therapy sessions specifically to you and your needs from day one. Healthy Pelvy Intake/ History Form: Name * First Name Last Name Email * Date of birth * Please describe the current problem that you're experiencing * When did your problem first begin? Was it related to a specific incident? If so, please describe the incident and the date: * Is pain present? Please rate it on a scale of 0-10/10, 10 being the worst. And please describe the nature of the pain (ex: burning, aching, heaviness) Have you tried any previous treatment or exercises? Are there any activities that cause or aggravate your symptoms? * What relieves your symptoms? * How has your lifestyle/quality of life been changed or altered because of your problem? This can include social activities, work, exercise, diet, and fluid intake * Please rate the severity this problem has in your life on a scale of 0-10, 10 being the worst: 0 1 2 3 4 5 6 7 8 9 10 What are your treatment goals or concerns? * How is your current health? * Excellent, good, fair, poor How much and what type of physical activity do you do? * How would you describe your mental health right now? Are you currently in therapy? * Have you experienced physical or sexual abuse? If you feel uncomfortable answering this at this time, you can leave this blank. Have you ever been diagnosed with another condition or diagnosis? If so, please include any and all: * Ex: cancer, heart problems, low back pain, fall on your tailbone, eating disorder, heady injury, sexually transmitted disease, asthma, sports injuries, etc. Have you ever had a surgery or procedure on your body? Please describe what and when below: * Ex: back/spine, brain, female organs, bladder/prostate, bones/joints, abdominal organs Please tell me about your Ob/Gyn history: Do you have children? How was the birthing experience? Did you labor for a long time? Have tearing? Do you have pain? Painful penetration? Do you currently have vaginal dryness? Painful periods? Menopause? Prolapse/organ falling out? Please include any and all medications that you are taking, including supplements and vitamins * Bladder habits: Tell me about your pee! * Do you pee right away when you sit on the toilet? Do you have to go all the time? Does it hurt before or during urination? Are you experiencing any leaking? Do you wear any protective pads? If so, what kind? How often do you change them? How many do you use a day? On average, how much do you leak? Just a few drops, fully wet underwear or liner? Bowel habits: How often do you have a bowel movement? What consistency is it? (You can look up the Bristol Stool Chart and compare!) Do you strain? Do you have leaking? * Please include anything else that you want to express that I didn't include in the above questions I understand that I am a patient of Kelsey Graham, OT, who is an independent Occupational Therapy practitioner practicing under HealthyPelvy LLC. * yes no I understand that Kelsey Graham, Healthy Pelvy Pelvic Floor Therapy cannot make any promises or guarantees regarding a cure for or improvements in my condition. * yes no I understand that Kelsey Graham will share her opinions regarding potential results of pelvic floor therapy for my condition and will discuss treatment options with me before I consent to treatment. * yes no I understand that I may experience an increase in my current level of pain or discomfort, or an aggravation of my existing injury. This discomfort is usually temporary; I will contact Kelsey if it does not subside in 24 hours. * yes no I understand that I may experience an improvement in my symptoms and an increase in my ability to perform my daily activities. I may experience decreased discomfort, and gain a great knowledge about my condition and resources available to me. * yes no I agree to pay for my sessions at the time of service by an agreed upon means * yes no I have read the above information and consent to pelvic floor therapy with Kelsey Graham. By checking the "yes" boxes above, I acknowledge that I have read, understood, and will abide by the conditions and policies noted on this form. yes no Thank you! I’ll review this and get back to you asap!
