Local: (905) 218-6556 | 341 Beach Blvd, Hamilton, ON
Fees & Insurance Coverage
Pure Pelvic Health New Client Health History
Step 1 of 7
This questionnaire is to be completed by clients of all ages and genders. There will be questions that do not apply to you. Simply leave these blank. *Required Questions
Address Line 2
State / Province / Region
ZIP / Postal Code
Antigua and Barbuda
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
British Indian Ocean Territory
Central African Republic
Congo, Democratic Republic of the
Congo, Republic of the
French Southern Territories
Heard and McDonald Islands
Isle of Man
Lao People's Democratic Republic
Northern Mariana Islands
Palestine, State of
Papua New Guinea
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Svalbard and Jan Mayen Islands
Trinidad and Tobago
Turks and Caicos Islands
US Minor Outlying Islands
United Arab Emirates
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Providing a cell number is very helpful during the COVID-19 pandemic so we can call you in your vehicle when you can come inside for your appointment.
Date of Birth
Date Format: MM slash DD slash YYYY
Emergency Contact Name
Emergency Contact Phone
What problem(s) would you like to address with pelvic physiotherapy?
Please list the problem(s) that you would like to address with pelvic floor physiotherapy.
How long have you had this issue(s)?
What do you think started this issue(s)?
What do you think is causing it?
What do you think will help to resolve it?
Pelvic floor symptoms (please check all that apply)
Leak urine with cough/sneeze/jump/lift/etc.
Strong urge to go to the bathroom (with leaking)
Strong urge to go to the bathroom (without leaking)
It feels like I always have to go to the bathroom
It feels like my bladder does not empty fully
Frequent urinary tract infections
Sexually active (now)
Sexually active (in the past)
Pain with sex (with penetration)
Pain with sex (throughout)
Pain with sex (after)
Difficulty with errections
Feelings of heaviness or pressure in vagina
Infrequent bowel movements (less than 3x/week)
Small, lumpy, or hard bowel movements
Need to strain to have a bowel movement
Back problems (upper back)
Back problems (middle back)
Back problems (lower back)
I have experienced abuse/assault (physical)
I have experienced abuse/assault (sexual)
I have experienced abuse/assault (emotional)
Please help us understand any other pelvic floor issues, symptoms or dysfunction that you may be experiencing.
Number of Pregnancies
Number of Vaginal Deliveries
Number of C-Sections
Years of deliveries
Forceps of Vacuum?
Are you currently breastfeeding?
Do you get regular periods?
If no, what is preventing them?
Medications FOR THIS CONDITION
Please list for each medication you are taking for THIS CONDITION: Medication name Dose Prescribed by Does it help? Currently taking?
Please list any other medications that you are currently taking
Please list any ABDOMINAL or PELVIC surgery
Please list any ABDOMINAL or PELVIC surgery that you have had. When did you have it and what was the procedure?
Family Physician Phone
Please send pelvic physiotherapy assessment report to family physician
Please list the physician specialists related to your pelvic health concerns (e.g., OBGYN, Urologist)
Specialist One Phone
Specialty (eg., OBGYN, urologist, etc.)
Please send pelvic physiotherapy assessment report to specialist one
Specialist Two Phone
Specialty (eg., OBGYN, urologist, etc.)
Please send pelvic physiotherapy assessment report to specialist two
Complimentary Healthcare Providers
Chiropractors, naturopath, etc. that you are currently seeing as a result of your pelvic health concerns.
Complimentary Healthcare Provider Name
Complimentary Healthcare Provider Phone
Complimentary Healthcare Provider Specialty
Please send pelvic physiotherapy assessment report to complimentary healthcare provider
Who referred you to Pure Pelvic Health?
Other Medical Conditions
Please check all that apply
High/low blood pressure
Fainting or dizziness
Are you currently under medical care for any of the following or have a history of any of the following:
Please list any other health conditions
Do you experience any of the following:
If yes, are you receiving treatment for any of these?
Vaginal or Rectal Examination
Your physiotherapist may suggest completing a vaginal or rectal exam as a part of your assessment and/or treatment. Is there anything that you would like to discuss with the physiotherapist prior to this?
Is there anything else that you think your physiotherapist should be aware of?
Central Sensitization Inventory
Please check the best response for each statement
I feel tired and unrefreshed when I wake from sleeping
My muscles feel stiff and achy
I have anxiety attacks
I grind or clench my teeth
I have problems with diarrhea and/or constipation
I need help in performing my daily activities
I am sensitive to bright lights
I get tired very easily when I am physically active
I feel pain all over my body
I have headaches
I feel discomfort in my bladder and/or burning when I urinate
I do not sleep well
I have difficulty concentrating
I have skin problems such as dryness, itchiness or rashes
Stress makes my physical symptoms worse
I have low energy
I have muscle tension in my neck and shoulders
I have pain in my jaw
Certain smells, such as perfumes, make me feel dizzy and nauseated
I have to urinate frequently
My legs feel uncomfortable and restless when I am trying to go to sleep
I have difficulty remembering things
I suffered trauma as a child
I have pain in my pelvic area
Canada's Anti-Spam Legislation (CASL) requires us to obtain your written consent before we send you any communications by email. We may occasionally contact you to: 1. Request your feedback regarding the services you have received from Pure Pelvic Health 2. Provide you with an invoice, receipt, or other billing related information 3. Remind you of an appointment or provide information or special instructions regarding your appointment 4. Provide you with valuable health and rehabilitation information
My consent to receiving email communication
Yes, I consent to receiving email communication from Pure Pelvic Health
While we understand that unexpected situations arise that may require you to cancel an appointment, please understand that due to the nature of our business it is difficult to place another client in a cancelled appointment time. Therefore, please be advised that we require a minimum of 24 hours notice to cancel an appointment. Last minute cancellations or "no shows" will be billed directly to the client at the following rates: Cancelled or missed appointments with less than 24 hours notice will result in a $20.00 billed to your account. During the COVID-19 pandemic we still appreciate your 24 hours notice. However, if you are unable to attend your scheduled appointment because of COVID-19 symptoms all cancellation fees will be waived. If you are feeling ill please do not attend your appointment.
My acknowledgment of appointment cancellation policy
I have reviewed and accepted the Pure Pelvic Health appointment cancellation policy
Consent to Assessment and Treatment
Thank you for the confidence and commitment you are demonstrating through your decision to pursue pelvic health physiotherapy. Before we get started, we would like to review some information regarding the internal component of your assessment and treatment. There are three main reasons that we assess and treat the pelvic floor muscles internally, either rectally or vaginally. The first is that these muscles cannot be palpated or reached externally, The second is that we are unable to ensure that your prescribed exercises are being completed properly. Lastly, and most importantly, we are assessing to see whether these muscles are lengthened and weak, or tightened and weak. This determination will dictate the course of your treatment. If we look at the research, there is clear evidence to suggest that giving written or verbal cues for pelvic floor muscle training does not constitute adequate training. Additionally, there are guidelines that recommend that pelvic floor muscle training be completed using an internal approach or biofeedback. Like any course of treatment, on rare occasions patients can experience the following adverse reactions: NAUSEA OR LIGHTHEADEDNESS, PAIN OR DISCOMFORT, SKIN IRRITATION OR REACTION TO LUBRICANT GEL, ANXIETY OR EMOTIONAL DISTRESS, BLEEDING DURING OR AFTER TREATMENT UNRELATED TO MENSES. Please inform your physiotherapist should any of these reactions occur. We cannot perform internal treatment on patients under the following circumstances. If any of these apply to you, or if this information changes in the future, please inform your physiotherapist: ACTIVE INFECTION, RADIATION INJURY LESS THAN 12 WEEKS, POST-OPERATIVE LESS THAN 6 WEEKS (12 WEEKS FOR PROLAPSE REPAIR), ACTIVE RECTAL BLEEDING, SEED IMPLANTS OF RADIOACTIVE MATERIALS, IF YOU ARE PREGNANT AND HAVE BEEN ADVISED BY YOUR DOCTOR TO ABSTAIN FROM INTERCOURSE. Potential benefits of treatment may include: DECREASED SYMPTOMS, IMPROVED STRENGTH, AWARENESS AND FLEXIBILITY, IMPROVED BLADDER/BOWEL CONTROL, DECREASED PAIN AND DISCOMFORT, IMPROVED ABILITY TO PERFORM DAILY ACTIVITIES, IMPROVED KNOWLEDGE AB OUT MANAGING AND TREATING YOUR CONDITION. If I do not wish to undergo the internal assessment and treatment of my pelvic floor, I will discuss alternatives with my physiotherapist, family doctor or my specialist.
Consent to internal assessment and treatment
I have read the above consent. I will be given an opportunity to ask questions and I will let my physiotherapist know about any concerns that I have. By checking here, I agree to internal assessment and/or treatment.