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Pelvic Floor Health
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Contact
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New Patient Portal
Pelvic Floor Health
Crossman Chiropractic
Women’s Pelvic Health History
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Name
*
First
Last
Address
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City
--- Select state ---
Alabama
Alaska
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Tennessee
Texas
Utah
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West Virginia
Wisconsin
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State
Zip Code
Email Address
Phone
Do you text on this number?
Yes
No
Vaginal began you
Date of Birth
Number of Pregnancies?
No pregnancy
One
Two
Three
Four
Five or more
Vaginal Birth
One
Two
Three
Four
Five or more
Miscarriage -- how many?
One
Two
Three
Four
Five or more
Are you less than 12 weeks post-partum?
Yes
No
Therapeutic abortion -- how many?
One
Two
Three
Four
Five or more
During delivery did you have a...?
Vaginal delivery
Cesarean birth
Episiotomy
Breech birth
Forceps delivery
Menopause Status
Pre-menopause
Peri-menopause
Menopause (12 months since your last menstruation)
Post-menopause
Do you have any medical conditions that increase intra-abdominal pressure?
Chronic cough
Constipation
Heavy lifting
Other than delivery or abortions have you had any pelvic surgeries for...?
The Bladder or urinary tract
Colon or rectal
Surgeries of the uterus or vagina
Hysterectomy
Cancer
When did you have the surgery? What was the surgery for?
Previous treatments for Pelvic Floor Health
Pelvic Floor Training
Surgery
Other modalities
What other modalities have you tried for Pelvic Floor Health?
Urinary Tract symptoms
Stress urinary incontinence
Overactive bladder symptoms (urgency, frequency, night time frequency)
Voiding difficulties
Do you experience...?
Leaking with cough, sneeze, laughing or positional changes and/or with lifting.
Feeling the need to urinate all the time.
Leaking urine when there is urge.
Pelvic pressure or pelvic heaviness.
Feeling like something is falling out of the vagina.
Fecal incontinence or inability to control gas.
Have you experienced...?
Vuvlodynia (pain of the vulva)
Pain during intercourse or during a vaginal exam
Endometriosis
Fibromyalgia
Painful bladder syndrome
Coccydynia
Inflammation of the vulva or perinium
Please mark any issue currently have
Active malignant tumor
Anticoagulation therapy
Cardiac disorders
Cardiac pacemakers
Dental implants
Diabetes
Drug pumps
Electronic implants
Hemorrhagic conditions
Hip replacement
Hypertension
Hypertension
Hemmorrhagic conditions
Hip replacement
Hypertension
Implanted defibrillator
Implanted neurostimulators
Kidney problems
Knee replacement
Metal stents
Metal IUD
Pelvic floor skin disease or sensitivity
Pelvic organ prolapse (Please note below which stage)
Pulmonary insufficiency
Shoulder replacement
If you have marked any issue above, please when it began and list all relevant information below,
Patient Signature
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Date
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