New Patient Intake Form — Pelvic Floor Physical Therapy

Section 1 of 7

Personal Information

Basic contact and demographic details to help us prepare for your visit.

Welcome — and thank you for taking the time to fill this in.

The more I know about you before we meet, the better I can prepare for your first session and make the most of our time together. Your answers help me understand your full picture — not just your symptoms, but your history, lifestyle, and goals.

🔒 Your responses are completely confidential and used only to guide your care.

First Name *

Last Name *

Date of Birth *

Preferred Pronouns

Phone Number *

Email Address *

Who referred you to our practice?

Referring provider's name (if applicable)

Have you seen a pelvic floor PT before?

Yes No, this is my first time

What did you see them for?

Section 2 of 7

Chief Complaint & Symptoms

Tell us what's brought you in. There are no wrong answers — the more detail you share, the better we can prepare for you.

Primary reasons for seeking pelvic floor PT * Select all that apply

Leaking urine (stress or urge) Urgency / sudden urge to urinate Pelvic or perineal pain Pain with sex / penetration Pelvic organ prolapse / heaviness Diastasis recti / core weakness Constipation / difficulty passing stool Bowel urgency or leakage Tailbone / coccyx pain Hip or low back pain Birth prep / perineal prep Return to exercise / sport I was told I need to — not sure why Postpartum check-up Other (describe below)

In your own words, describe what's been going on: When did it start? What makes it better or worse?

How long have you been experiencing these symptoms?

What are your goals for therapy?

Section 3 of 7

Obstetric & Gynecological History

This information helps us understand your pelvic history and any relevant events that may influence your treatment.

Current status *

Postpartum Currently pregnant Trying to conceive Not pregnant / not trying Perimenopause Post-menopause

How many weeks/months postpartum are you?

Type of delivery Select all that apply

Vaginal (unassisted) Vaginal with forceps Vaginal with vacuum Cesarean (planned) Cesarean (emergency)

Perineal trauma Select all that apply

None / intact Episiotomy 1st degree tear 2nd degree tear 3rd degree tear 4th degree tear Unsure

Are you currently breastfeeding / chestfeeding?

Yes No

How many weeks pregnant are you?

Has your OB/midwife cleared you for pelvic PT?

Yes Not yet / pending Unsure

Number of pregnancies (including current)

Number of live births

History of pregnancy loss?

Yes No Prefer not to say

Gynecological diagnoses Select all that apply

Endometriosis Uterine fibroids PCOS Vaginismus Vulvodynia / vestibulodynia Pelvic organ prolapse Lichen sclerosus None Other

Please describe:

Previous pelvic/abdominal surgeries Select all that apply

Cesarean section Hysterectomy Laparoscopy / laparotomy Appendectomy Mesh repair / sling None Other

Section 4 of 7

Bladder Habits

Bladder habits provide important clinical clues. Please answer as accurately as possible — there is no "normal" here.

How many times do you urinate during the day?

How many times do you wake at night to urinate?

Do you experience urinary leakage?

Yes No

What triggers the leakage? Select all that apply

Coughing / sneezing Exercise / jumping Lifting / bending Sudden strong urge Key in door / arriving home Hearing running water During / after sex Continuous / no trigger

How much do you typically leak?

A few drops Small amount (spot on pad) Large soaking amount

Do you wear pads or protection for leakage?

Yes No

Do you have urgency — a sudden, strong need that is hard to defer?

Yes No Sometimes

Do you have difficulty fully emptying your bladder?

Yes — feels incomplete No Not sure

Do you urinate "just in case" even without a strong urge?

Yes, frequently Sometimes No

Approximate daily fluid intake

Section 5 of 7

Bowel Habits

Bowel function is closely linked to pelvic floor health. Please answer as accurately as you can.

How often do you have a bowel movement?

Typical stool consistency

Type 1–2: Hard / difficult to pass Type 3–4: Normal / sausage-shaped Type 5–6: Soft / mushy Type 7: Watery / liquid Varies significantly

Do you experience any of the following? Select all that apply

Straining to pass stool Feeling of incomplete emptying Pain during/after bowel movement Bowel urgency / racing to toilet Fecal leakage / soiling Gas / flatulence leakage Significant bloating Hemorrhoids None of the above

Do you take any medications or supplements for bowel regulation?

Yes No

Please list:

Section 6 of 7

Pain & Sexual Health

These questions help us understand pelvic pain patterns and how symptoms affect intimacy. Please share only what you're comfortable with.

🔒 Your responses are completely confidential and used only to guide your care.

Do you experience pelvic or perineal pain?

Yes No

Pain location Select all that apply

Vulva / labia Vagina / internally Perineum Clitoris / urethral area Rectum / anus Tailbone / coccyx Low back / sacrum Hips / SI joint Lower abdomen

Pain quality Select all that apply

Aching / dull Burning Sharp / stabbing Pressure / heaviness Throbbing / pulsing Rawness / soreness

Average pain level (at rest)

0 10 3

No painWorst imaginable

Average pain level (at worst)

0 10 6

No painWorst imaginable

Are you currently sexually active? Helps us understand how symptoms affect your daily life

Yes No — symptoms prevent it No — personal choice Prefer not to say

Do you experience pain with penetration? Vaginal intercourse, tampons, gynecological exams, etc.

Yes — at entry / externally Yes — deep / internal Yes — both After sex / next day No pain

Do you experience difficulty with penetration (tightness, inability to allow entry)?

Yes No Sometimes

Has sexual activity changed since symptoms began? Select all that apply

Avoided / stopped sex Less frequent sex Affecting my relationship No significant change

Section 7 of 7

Medical History & Lifestyle

A few final questions about your overall health and lifestyle to complete your intake.

Relevant medical history Select all that apply

IBS / IBD / Crohn's Fibromyalgia Hypermobility / EDS Autoimmune condition Anxiety / depression History of pelvic trauma or abuse Cancer (pelvic / abdominal) Diabetes None of the above

Current medications Including hormones, birth control, antidepressants, pain medications

Do you currently exercise? Select all that apply

Not currently Walking / gentle movement Yoga / Pilates Strength training Running / high-impact cardio Swimming Cycling CrossFit / HIIT Other

How many times per week do you exercise?

Do any activities worsen your symptoms?

Occupation / main activity level Helps us understand your daily load

Is there anything else you'd like your therapist to know before your first session?

I confirm that the information I have provided is accurate to the best of my knowledge, and I consent to this information being used to guide my physical therapy care. *

✓

Thank you for completing your intake form.

I will review your responses before your first session.

Looking forward to meeting you and supporting your pelvic health journey.

If you have any questions before your appointment, please don't hesitate to reach out.