New Patient Intake and Health History

Pure Pelvic Health New Patient Intake and Health History

Patient contact information

First Name *

Last Name *

Date of Birth *

Your Pronouns

Who referred you to Pure Pelvic Health?

Street Address 1 *

Street Address 2

City *

Province

Postal Code *

Mobile or Primary Phone Number (please use format 000-000-0000) *

Secondary Phone Number (please use format 000-000-0000)

Email *

Emergency Contact

Emergency Contact First Name *

Emergency Contact Last Name *

Emergency Contact Phone Number (please use format 000-000-0000) *

Gynecological history if applicable

Are you currently pregnant?

Yes

No

If you are currently pregnant, what is your due date?

Number of pregnancies

Number of vaginal deliveries

Number of C-sections

Baby weights

Years of deliveries

Tearing?

Episiotomy?

Forceps or vacuum?

Are you currently breastfeeding?

Yes

No

Do you get regular periods

Yes

No

If no, what is preventing them?

Family Doctor

Family Doctor First name

Family Doctor Last name

Family Doctor Phone Number (please use format 000-000-0000)

I consent to sharing my Pure Pelvic Health initial assessment report with my family physician to facilitate continuation of care and the best possible treatment outcome *

Yes

No

Physician specialists for this condition

Specialist One

Physician Specialist First name

Physician Specialist Last name

Specialty (e.g., OBGYN, Urologist, etc)

Specialist Two

Physician Specialist First name

Physician Specialist Last name

Specialty (e.g., OBGYN, Urologist, etc)

I consent to sharing my Pure Pelvic Health initial assessment report with my physician specialist to facilitate continuation of care and the best possible treatment outcome

Yes

No

Complimentary healthcare providers for this condition

Complimentary Provider One

Complimentary Provider First name

Complimentary Provider Last name

Provider type (e.g., chiropractor, naturopath)

Complimentary Provider Two

Complimentary Provider First name

Complimentary Provider Last name

Provider type (e.g., chiropractor, naturopath)

I consent to sharing my Pure Pelvic Health initial assessment report with my complimentary healthcare providers continuation of care and the best possible treatment outcome

Yes

No

Electronic Communication

Canada's Anti-Spam Legislation (CASL) requires us to obtain your written consent before we send you any communications by email (or text). 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 and / or text communication from Pure Pelvic Health *

Yes, I consent to receiving electronic communication from Pure Pelvic Health

Cancellation Policy

Pure Pelvic Health requires 48 hours notice to cancel or reschedule an appointment. Patients cancelling or rescheduling appointments with less than 48 hours notice will be charge a fee equal to 50% of the scheduled service. Patients cancelling the day of their appointment or not showing up for their scheduled appointment will be charged a fee equal to 100% of the scheduled service. We understand that unexpected situations do arise and we will work with you to avoid late fees whenever possible. Please note that we have a long list of patients waiting for appointments and when you cancel without adequate notice it is more difficult for other patients to adjust their schedules to accommodate a last minute cancellation.

My acknowledgement of the Pure Pelvic Health cancellation policy *

I have reviewed and accepted the Pure Pelvic Health 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.

My consent to assessment and treatment *

I have read the statement above. I understand that I will be given an opportunity to ask questions and I will let my physiotherapist know about any concerns that I have. My checking here, I agree to treatment and an assessment that may include an internal assessment. I understand that I can withdraw my consent at anytime.

Thank you for completing your Pure Pelvic Health new patient intake forms. Your forms have been successfully transmitted to Pure Pelvic Health and will be reviewed by your physiotherapist prior to your first appointment.

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