Women's Health Physical Therapy Intake Form
Personal Information
Full Name
Date of Birth
Address
Phone Number
Email
Emergency Contact Name & Phone
Referring Doctor / Reason For Referral
Referring Doctor
Reason for Physical Therapy
Medical History
Current Diagnoses / Medical Conditions
Current Medications
Allergies
Past Surgeries (list and dates)
Obstetric & Gynecological History
Number of Pregnancies
Number of Children
Type of Deliveries
Date of Last Menstrual Period
Menopausal Status
No
Yes
Gynaecological Problems
Contraceptive Use
Symptoms
Please describe your current symptoms
Duration of symptoms
What aggravates your symptoms?
What relieves your symptoms?
Bladder & Bowel
Urinary problems?
Bowel problems?
Any sexual health concerns?
Goals for Therapy
What are your goals for therapy?