Initial Pelvic Floor Physiotherapy

We require some information from you prior to your initial consultation with Jessica Frydenberg.

Please complete the form below.

The initial consultation with Jessica is primarily for extensive education about all pelvic floor issues regardless of what you may be suffering from. This is to ensure you fully understand all aspects of the bladder, bowel and pelvic floor in order to prevent any further problems in future years.  Jessica tailors her treatment to your specific needs to ensure you are receiving the best possible treatment relevant to your condition.  Pelvic floor dysfunction, bladder and bowel problems tend to get worse with aging and good education can prevent some of these distressing conditions from occurring further down the track. 




Please list the three key goals you would like to address from this consultation:
1.
2.
3.

Do you have a latex allergy?

Do you have any other allergies?

If YES, please list blow:

THE AUSTRALIAN PELVIC FLOOR QUESTIONNAIRE
Please select your most applicable answer. Consider your experiences during the last month.

BLADDER FUNCTION
1. How many times do you pass urine in the day?

2. How many times do you get up night to pass urine?

3. Do you wet the bed before you wake up at night?

4. Do you need to rush or hurry to pass urine when you get the urge?

5. Does urine leak when you rush or hurry to the toilet. Can you make it in time?

6. Do you leak with coughing, sneezing, laughing or exercising?

7. Is your urinary stream (urine flow) weak, prolonged or slow?

8. Do you have a feeling of incomplete bladder emptying?

9. Do you feel you need to strain to empty your bladder?

10. Do you have to wear pads because of urinary leakage?

11. Do you limit your fluid intake to decrease leakage?

12. Do you have frequent bladder infections?

13. Do you have pain in your bladder or urethra when you empty your
bladder?

14. Does urine leakage affect your daily routine activities like recreation, socialising, sleeping, shopping etc?

15. How much does your bladder problem bother you?

Other symptoms:

BOWEL FUNCTION
16. How often do you usually you’re your bowels?

17. How is the consistency of your usual stool?

18. Do you have to strain a lot to empty your bowels?

19. Do you use laxatives to empty your bowels?

20. Do you feel constipated?

21. When you get wind or flatus, does wind leak?

22. Do you get an overwhelming sense of urgency to empty your bowels?

23. Do you leak watery stool when you don’t meant to?

24. Do you leak normal stool when you don’t mean to?

25. Do you have a feeling of incomplete bowel empyting?

26. Do you use finger pressure to empty your bowel?

27. How much does your bowel problem bother you?

MALE NIH - Chronic Prostatitis Symptom Index (NIH-CPSI)
If pain is not an issue, you do not need to complete the remaining questions. Please click "send" now.
PAIN OR DISCOMFORT

1. In the last week, have you experienced any pain or discomfort in the following areas:
a. Area between rectum and testicles(perineum)

b. Testicles

c. Tip of the penis (not related to urination)

d. Below your waist, in your pubic or bladder area

2. In the last week, have you experienced:
a. Pain or burning during urination

b. Pain or discomfort during or after sexual climax (ejaculation)

3. How often have you had pain or discomfort in any of these areas over the last week?

4. Which number best describes your AVERAGE pain or discomfort on the days that you had it, over the last week?

URINATION
5. How often have you had a sensation of not emptying your bladder completely after you finished urinating over the last week?

6. How often have you had to urinate again less than two hours after you finished urinating, over the last week?

IMPACT OF SYMPTOMS
7. How much have your symptoms kept you from doing the kinds of things you would usually do, over the last week?

8. How much did you think about your symptoms, over the last week?

QUALITY OF LIFE
9. If you were to spend the rest of your life with your symptoms just the way they have been during the last week, how would you feel about that?

We respect the privacy of our patients and any information provided remains confidential.