SCREENING QUESTIONNAIRE - Specialty Physical Therapy



Specialty Physical TherapyAnswering the following questionnaires will help us to manage your care better. Please complete all pages prior to your appointment.Name:________________________________________Date:_________________________Age____________Height__________________Weight_______________Date of last doctor visit ___________last pelvic exam______ last urinalysis__________Previous tests for the condition for which you are coming to physical therapy? _______Please list tests____________________________________________________________Is this a work-related or auto injury? ____ If yes, date of injury___________Have you seen a physical therapist this year? ______ If yes, how many visits have you had this year______Are you seeing a chiropractor? _____If yes, how many visits have you had this year_____May we obtain x-ray/MRI/CT scans/reports re: this condition? _____How did you hear about Specialty Physical Therapy? __________________________________________________________________________Do you now have or have you had a history of the following? Explain yes responses and include dates.Y/N Bladder infectionsY/N ConstipationY/N Pelvic painY/N Joint problemsY/N Low back pain/sciaticaY/N Abdominal painY/N DiabetesY/N Broken bonesY/N Multiple SclerosisY/N Heart diseaseY/N StrokeY/N Emphysema/BronchitisY/N AllergiesY/N High blood pressureY/N AsthmaY/N Sexually transmitted diseasesY/N Childhood bladder problemsY/N HIV/AIDSY/N Trouble holding back gasY/N Fecal incontinenceY/N Trouble initiating urine streamY/N Smoking habitY/N Vaginal drynessY/N Trouble emptying bladderY/N Constant dribbling of urineY/N Blood in urineY/N Trouble feeling bladder fullnessY/N Bladder cancerY/N Other (please list)Explanation of the above responses _________________________________________________________________________________________________________________________________________________________________________________________________________________________________Surgical HistoryY/N Surgery for your back/ spine? Y/NSurgery for bladder?Y/NSurgery for your brain?Y/NSurgery for prostate?Y/NSurgery for your female organs?Y/NSurgery for abdominal organs?Y/NOther type please describe____________________________________________Ob/Gyn History (females only)Y/NPainful periodsY/NMenopause Date of last period ____Y/NPainful penetrationY/NC-Section #____Y/NVaginal deliveries #_____Y/NEpisiotomy #_____Y/NProlapse or falling out feelingY/NDifficult childbirthExplain yes responses___________________________________________________ Please list all medications with start date and reason for taking:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Describe the reason for your appointment___________________________________________When did this problem begin? _____ Is it getting better____ worse____staying the same ____List activities or things that you cannot do because of this problem______________________________________________________________________________________________________________________________________________________Symptom Questionnaire1. Bladder leakage frequency -number (#) of episodesNeverOnly with strong cough/sneezeOnly premenstrual___ # per month___ # per week___ # per dayConstant leakage2. Severity of leakage (circle one)No leakage Few dropsWets underwearWets outerwear3. Protection worn (circle one)NoneTissue paper / paper towelPantishieldsMinipadsMaxipadSpecialty product name____________4. Leakage caused or increased by (circle all that apply)Vigorous activity or exercise (running, weight lifting)Light activity (walking, light housework)Changing positions (sit to stand)Walking to the toiletStrong urge to goIntercourse or sexual activityNo activity changes leakage (constant despite activity)Other, please list_________________________________________________5. Position or activity with leakage. (all that apply)Lying downSittingStanding6. How long can you delay the need to urinate? (Circle one)Not at all1-2 minutes3-10 minutes11-30 minutes31-60 minutes_____ Hours7. Rate a feeling of "falling out "or pelvic heaviness/pressureNone present____ Times per monthOnly with menstruationWith standingWith exertion or strainingAt the end of each dayPresent all day8. Fluid intake (one glass is 8 oz. or one cup)_____ Glasses per day# of caffeinated glasses______per day# of alcoholic beverages_____per day9. Rate your feelings as to the severity of this problem from 0-10 with 10 being the worst0_________________________________________________10not a problemmajor problem10. Rate the following statement as it applies to you todayMy bladder is controlling my life.0_________________________________________________10not true at allcompletely trueBladder HabitsHow often do you urinate during the day? ____# of timesHow often do you urinate after going to bed? ____# of timesDo you take your time to go to the toilet and empty your bladder? _____ Y/NNumber of bladder infections in the last year? ______Can you stop the flow of urine when on the toilet? Y/NIs the volume of urine passed usually; Large Average Small Very smallDo you have the sensation that you need to go to the toilet? Y/NDo you strain to pass urine? Y/NDo you empty your bladder frequently, before your experience the urge to pass urine? Y/NDo you have the feeling your bladder is still full after urinating? Y/NDo you have a slow or hesitant urinary stream? Y/NDo you have difficulty initiating the urine stream? Y/NDo you have "triggers" that make you feel like you can't wait to go to the toilet? (running water, etc.) Y/N please list_____________________________________________________Bowel HabitsFrequency of bowel movements ___ per day ____ per weekConsistency of stool loose__ normal___ hard__History of constipation? Y/NDo you currently strain to go? Y/NDo you ignore the urge to defecate? Y/NDo you have trouble making it to the toilet on time when you have an urge to go? Y/NI certify that the information above is correct to the best of my knowledge. I understand and agree that I am personally responsible for full payment of all physical therapy services rendered to me. I hereby transfer/assign payment of any physical therapy insurance benefits directly to Specialty Physical Therapy and authorize release of any information regarding my treatment that is required by my insurance carrier to obtain such payment.Signature___________________________________________Date__________ ................
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