Pure Pelvic Health New Client Health History | Pure Pelvic Health

Step 1 of 7

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?

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.