Core Physical Therapy

1971 Western Avenue Albany, NY  12203

Phone: (518) 869-6220

Fax: (518) 869-6465

Name______________________                                                Date of Birth_________________

Address ___________________                                                Telephone Number

__________________________                                                Home_________________

Occupation__________________                                                Work_________________

Insurance Carrier______________                                                Cell__________________

ID#____________________                                                Referring MD_______________ Date_____________                                                            MD phone__________________

What is your present complaint? ___________________________________________  ________________________________________________________________________

How long have you been with this complaint? ________________________________________________________________________

List your past surgeries or major medical problems: __________________________ ________________________________________________________________________________________________________________________________________________

Are you currently being seen for any other medical problems? If so, what are they?  ___________________________________________________________________________________

What have you tried to treat this problem before and was it beneficial, harmful, or not effective?

________________________________________________________________________

What do you do that increases your complaint?_______________________________________

What do you do that decreases your complaint?______________________________________

Bladder Symptoms:

Do you lose urine when you:                 Cough/Sneeze/Laugh             Y   /   N

                                                              Lift/Exercise/Jump                  Y   /   N

                                                              On the way to the restroom   Y   /   N

                                                              Hear running water                 Y   /   N 

Do you:

 Have a strong urge to urinate?            Y   /   N

Wet the bed?      Y  /  N

Have burning pain with urination?   Y  /  N

Have difficulty starting a stream of urine?  Y  /  N

Strain to empty your bladder?   Y  /  N

Feel unable to empty your bladder fully?  Y  /  N

Have a falling out feeling?  Y  /  N

Have pain with a full bladder?  Y  /  N

Have an urgency to urinate?  Y  /  N

Urinate more than 7 times in a day?  Y  /  N

How many glasses of fluids do you intake per day?    Water ______     Caffeine ______                      Alcohol ______   Other______

How many times do you urinate during the day? ________        night? _________

Do you wear leakage protection?   Y  /  N      Liner _____     Mini Pad _____    Adult Pad _____            How many per day do you use? _______

How old were you when you started to menstruare? _____      Are/Were the cycles regular? _______      At any time were they painful? ______________

How old were you when you first became sexually active? _______ Was it painful? _________

Any history of abuse? Y  /  N   __________

Any history of falls on the pelvis or tailbone? Y  /  N   _________

Bowel Symptoms:

Do you:

Strain to have a bowel movement?  Y  /  N                 Leak or stain feces?  Y  /  N

Include fiber in your diet?  Y  /  N                   Have diarrhea often?  Y  /  N

Take laxatives or use enemas regularly?  Y  /  N               Leak gas by accident?  Y  /  N

Have pain with bowel movements?  Y  /  N           Have a very strong urge to move your bowels?  Y  /  N

How often you move your bowels? ________________ per day, week? _______________

Most common stool consistency:    Liquid ______      Soft _______     Firm _______     Pellets ______    Other _______

Sexual Symptoms:

Do you:

Have pain with intercourse?  Y  /  N                  Pain after sex?  Y  /  N

Tolerate manual sex?  Y  /  N                 Oral sex?  Y  /  N

Do you need lubricant?  Y  /  N                 Are you able to climax?  Y  /  N

 

Thank you for filling out this questionnaire!