Panther Pelvic Floor Therapy Questionnaire

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Patient Name:

Date of Birth:

Date:

Clinic Location:

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History

Number of Pregnancies (Dates):

Number of Vaginal Deliveries:

Birth Weight of Largest Baby:

Number of Cesareans:

Number of Live Children:

Number of Episiotomies:

Vaginal Tearing (severity):

YesNo

Grade

Did you have any trouble healing after delivery?

YesNoN/A

Are you having regular periods/ menstrual cycles?

YesNo

1st Day of Last Cycle:

Do you have frequent urinary tract or yeast infections?

YesNo

Are you currently sexually active?

YesNo

Age of first sexual experience?

History of sexual abuse?

YesNo

History of sexually transmitted infection(s)/ disease(s)?

YesNo

List any sexually transmitted infection(s)/ disease(s):

Pain

Do you have pain with:

Sexual intercourse?

YesNo

Pelvic exams?

YesNo

Tampon use?

YesNo

Presence of back/leg/groin/abdominal pain?

YesNo

Bladder Symptoms

Do you lose urine when you:

Cough/ Sneeze/ Laugh?

YesNo

Lift/ Exercise/ Dance/ Jump?

YesNo

On the way to the bathroom?

YesNo

Have a strong urge to urinate?

YesNo

Hear running water?

YesNo

Other reason you lose urine:

Do you wet the bed?

YesNo

Have burning/ pain with urination?

YesNo

Difficulty starting a stream of urine?

YesNo

Strain to empty your bladder?

YesNo

Strain to empty your bladder?

YesNo

Stand up or reposition to improve ability to void more urine?

YesNo

Feel unable to empty bladder fully?

YesNo

Have a falling out feeling?

YesNo

Have pain with a full bladder?

YesNo

Have a strong urge to urinate?

YesNo

Urinate more than 7 times per day?

YesNo

Bowel Symptoms

Do you strain?

YesNo

Do you leak feces?

YesNo

Do you have pain with bowel movements?

YesNo

Do you have strong urge to move your bowels?

YesNo

How often do you move your bowels? (Times per day/ week- Please specify per day or week in your response)

Most common stool consistency?

LiquidSoftFirmPellets

Do you use pads?

YesNo

Do you use pads for leakage of:

BladderBowelBoth

Number of pads used per day

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