Women's Health Physical Therapy Evaluation Form
Name
Date of Birth
Evaluation Date
Referral Source
Primary Complaint/Reason for Visit
Occupation
Handedness
Right
Left
Both
Relevant Medical/Surgical History
Other Current/Past Medical Conditions
Obstetric History (if applicable)
Gynecologic History
Menstrual History
Sexual History
Current Medications
Pain Description (location, intensity, type)
Symptom Aggravating Factors
Symptom Easing Factors
Bladder Function
Bowel Function
Activities Impacted (functional limitations)
Observation/Posture
Palpation Findings
Range of Motion
Strength
Special Tests
Pelvic Floor Muscle Assessment
Assessment / Impression
Goals
Plan of Care / Recommendations
Therapist Name
Signature
Date