Patient Details

Title *

Last Name: *

Preferred Name

First Name: *

Date of Birth *

Gender *

MaleFemaleNon-binaryDifferent identity

Pronouns:

He/Him/HisShe/Her/HersThey/Them/TheirsOther

Occupation *

Email Address *

Home Phone

Mobile *

Work Phone

Address Line 1: *

Suburb: *

State: *

Post Code: *

Emergency Contact

Next of Kin

Relationship

Contact Number/s

GP Information

GP Name

Clinic

Referrer Information (if different from GP information)

Please tell us who to thank for referring you to our clinic

(if different from above GP details)

Referrer Name

Referrer Clinic

Privacy Statement

Your personal health information and your Records may be collected, used and disclosed, including but not limited to, the following reasons:

For communicating relevant information with treating doctors, specialists, insurers or other allied health professionals
For use by all physiotherapists in this practice, when consulting you
For research purposes (de-indentified, meaning you are not able to be indentified from information given)

If you have any concerns or wish to restrict access to your personal health information, please discuss these with your treating physiotherapist.

ALL PATIENT PLEASE READ AND SIGN

DECLARATION: I understand and agree that:

If I am unable to attend my appointment I will give 24 HOURS notice of my cancellation. If I do not cancel with notice I will be charged a Non-Attendance Fee of $55 for my missed appointment.
I am required to pay on the day for all consultations. Body Logic Pelvic Health Clinic accepts, cash, cheques and has EFTPOS and HiCaps facilities. If my account is not paid at the time of consultation, administration fee maybe added.
In the event that my accounts are outstanding longer than 45 days, I will be responsible for all collection fees incurred.
For insurance claims, I will be personally responsible for payment of all accounts incurred by me in the event that liability is denied, or placed in dispute by the insurance company.
I consent to treatment provided by the physiotherapist.

Any comments in regards to your appointment:

Documents relating to your appointment:

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Signature: *

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Date: *

Intake Questionnaires

We take a whole-person approach to your symptoms. We recognize that pain, bladder/bowel symptoms, muscle spasm and other symptoms have both a physical and emotional component to them. To get to the root of your problem(s), we will be asking you questions that will help us to fully assess your problem and the impact that it is having on your life. Please complete these questionnaires. If any of these questions don’t apply to you or your symptoms, just leave them blank. Thank you for taking the time to share your story with us!

Reason for your visit: *

What goals would you like to achieve by attending physiotherapy? *

Overall, how bothersome has your condition been in the last 4 weeks? *

Please description of symptoms: *

GENERAL HEALTH:

If any Neurological medical conditions, please provide details:

If any Urinary Tract Infection, please give more information on last UTI and the frequency of you UTI:

Medication:

Any other exercise not listed?

Frequency of exercise:

FEMALE:

Hormonal Therapy:

Systemic Hormone Replacement TherapyOral Contraceptive PillsTopical cream (Ovestin, Vagifem or other)

Number of pregnancies:

Number of vaginal deliveries:

Number of C-sections:

MALE:

Please select one if any applicable:

ProstatitisPSA

Central Sensitisation Inventory:

Please select the best response to each statement:

Please note that ALL of the questions below will need to be completed

Total:

Bladder Control Questioannire (ICIQ-SF)

Please answer the following questions, thinking about how you have been, on average, over the past four weeks.

How often do you leak urine? *

How much urine do you think leaks? *

Overall, how much does leaking urine interfere with your everyday life? *

When does urine leak? *

The Pelvic Health Psychological Screening Questionniare (3PSQ)

Everyone experiences painful situations at some point in their lives. We are interested in the thoughts and feelings that you have when you are experience pelvic symptoms and pain pelvic pain and how you cope with it.

PART B: During my life...

I have had a stressful or traumatic life event that has had a negative impact on me (T) *

PART C:

If you have been sexually active in the past month, please answer the following questions:

Never (0)Rarely (1)Sometimes (2)Often (3)Always (4)

If you have been sexually active in the past month, please answer the following question:

Never (4)Rarely (3)Sometimes (2)Often (1)Always (0)

If your form does not want to submit, please make sure you have answered all the quetions marked with a *

If you have pelvic pain please complete the following questionnaires to help us understanding how your pain impacts your life.

Thank you for answering our questionnaire, we greatly appreciate your time and patience!