Call Now!
(905) 218-6556
Call Now!
(905) 218-6556
341 Beach Blvd, Hamilton, ON
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Pure Pelvic Health New Client Health History
Step
1
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Health History
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
Name
*
First
Last
Your pronouns
Extended Health Insurance(s) (please check all that apply)
*
Great-West Life
Canada Life
SunLife
ManuLife
Equitable Life
OTIP
Green Shield Canada
Other
None (I will not be submitting this expense to an extended health insurer)
Pure Pelvic Health does not provide direct billing to extended health insurance but we do want to make it as easy as possible for you to submit a claim. Please let us know which insurance companies you will be submitting to (Primary & Secondary Coverage) and we'll do our best to make sure you have everything you need to submit for reimbursement. Please Note: Pelvic floor physiotherapy will be reimbursed up to your policy limits for physiotherapy.
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Home Phone
Cellular Phone
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
*
MM slash DD slash YYYY
Emergency Contact Name
*
First
Last
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)?
Please indicate any previous treatment you have had for 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
Bedwetting (pediatrics)
Sexually active (now)
Sexually active (in the past)
Pain with sex (with penetration)
Pain with sex (throughout)
Pain with sex (after)
Difficulty with erections
Painful erections
Feelings of heaviness or pressure in vagina
Prolapse
Painful Periods
Fecal Incontinence
Constipation
Infrequent/irregular periods
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)
Neck problems
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.
Gynecological History
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
Episiotomy?
Tearing?
Forceps or Vacuum?
Are you currently breastfeeding?
Do you get regular periods?
If no, what is preventing them?
Medications
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?
OTHER medications
Please list any other medications that you are currently taking
Surgical History
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
Family Physician
First
Last
Family Physician Phone
I consent to sharing my Pure Pelvic Health initial assessment report with my family physician to facilitate continuation of care and the best possible patient outcome.
*
Yes
No
Physician Specialists (including midwives) for this condition
Please list the physician specialists related to your pelvic health concerns (e.g., OBGYN, Urologist, midwife)
Specialist One
First
Last
Specialist One Phone
Specialty (eg., OBGYN, urologist, midwife, etc.)
I consent to sharing my Pure Pelvic Health initial assessment report with my medical specialist to facilitate continuation of care and the best possible patient outcome
Yes
No
Specialist Two
First
Last
Specialist Two Phone
Specialty (eg., OBGYN, urologist, midwife, etc.)
I consent to sharing my Pure Pelvic Health initial assessment report with my medical specialist to facilitate continuation of care and the best possible patient outcome
Yes
No
Complimentary Healthcare Providers
Chiropractors, naturopath, etc. that you are currently seeing as a result of your pelvic health concerns.
Complimentary Healthcare Provider Name
First
Last
Complimentary Healthcare Provider Phone
Complimentary Healthcare Provider Specialty
I consent to sharing my Pure Pelvic Health initial assessment report with my complimentary healthcare provider to facilitate continuation of care and the best possible patient outcome
Yes
No
Who referred you to Pure Pelvic Health?
Other Medical Conditions
Please check all that apply
Heart disease
High/low blood pressure
Diabetes
Cancer
Endometriosis
Fainting or dizziness
Headaches/migraines
Osteoporosis
IBS
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:
Stress
Anxiety
Depression
If yes, are you receiving treatment for any of these?
Internal 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 consenting to an internal examination?
Your consent to a vaginal or rectal examination is never assumed. Your physiotherapist will discuss consent with you at the time of your assessment and your consent can be withdrawn at any time.
Is there anything else your physiotherapist should be aware of?
If there is something you would like to share with your physiotherapist in advance of your appointment?
Central Sensitization Inventory
Please check the best response for each statement
I feel tired and unrefreshed when I wake from sleeping
*
Never 0
Rarely 2
Sometimes 2
Often 3
Never 4
My muscles feel stiff and achy
*
Never 0
Rarely 1
Sometimes 2
Often 3
Always 4
I have anxiety attacks
*
Never 0
Rarely 1
Sometimes 2
Often 3
Always 4
I grind or clench my teeth
*
Never 0
Rarely 1
Sometimes 2
Often 3
Never 4
I have problems with diarrhea and/or constipation
*
Never 0
Rarely 1
Sometimes 2
Often 3
Always 4
I need help in performing my daily activities
*
Never 0
Rarely 1
Sometimes 2
Often 3
Always 4
I am sensitive to bright lights
*
Never 0
Rarely 1
Sometimes 2
Often 3
Always 4
I get tired very easily when I am physically active
*
Never 0
Rarely 1
Sometimes 2
Often 3
Always 4
I feel pain all over my body
*
Never 0
Rarely 1
Sometimes 2
Often 3
Always 4
I have headaches
*
Never 0
Rarely 1
Sometimes 2
Often 3
Always 4
I feel discomfort in my bladder and/or burning when I urinate
*
Never 0
Rarely 1
Sometimes 2
Often 3
Always 4
I do not sleep well
*
Never 0
Rarely 1
Sometimes 2
Often 3
Always 4
I have difficulty concentrating
*
Never 0
Rarely 1
Sometimes 2
Often 3
Always 4
I have skin problems such as dryness, itchiness or rashes
*
Never 0
Rarely 1
Sometimes 2
Often 3
Always 4
Stress makes my physical symptoms worse
*
Never 0
Rarely 1
Sometimes 2
Often 3
Always 4
I have low energy
*
Never 0
Rarely 1
Sometimes 2
Often 3
Always 4
I have muscle tension in my neck and shoulders
*
Never 0
Rarely 1
Sometimes 2
Often 3
Always 4
I have pain in my jaw
*
Never 0
Rarely 1
Sometimes 2
Often 3
Always 4
Certain smells, such as perfumes, make me feel dizzy and nauseated
*
Never 0
Rarely 1
Sometimes 2
Often 3
Always 4
I have to urinate frequently
*
Never 0
Rarely 1
Sometimes 2
Often 3
Always 4
My legs feel uncomfortable and restless when I am trying to go to sleep
*
Never 0
Rarely 1
Sometimes 2
Often 3
Always 4
I have difficulty remembering things
*
Never 0
Rarely 1
Sometimes 2
Often 3
Always 4
I suffered trauma as a child
*
Never 0
Rarely 1
Sometimes 2
Often 3
Always 4
I have pain in my pelvic area
*
Never 0
Rarely 1
Sometimes 2
Often 3
Always 4
Electronic Commiunication
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
Cancellation Policy
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 without reasonable notice. 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 appointments with less than 24 hours notice will result in a $20.00 fee billed to your account. A missed appointment or a no show without any notice will result in a $50.00 fee 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. I understand that I can withdraw my consent at anytime.