Pelvic Health Intake Form

Pelvic floor physical therapy is a unique type of physical therapy requiring specialized training that includes internal and external evaluation of the pelvic floor muscles, and interventions involving the respiratory system, lumbar spine, hip and sacroiliac joints. All interventions are performed only after obtaining patient consent. If you have specific questions about this type of physical therapy, don't hesitate to reach out. Please complete this form ahead of your session with Dr. Molly Weinbender with MovementX, which will help us form a comprehensive picture of your symptoms and your goals.

This should take about 15-20 minutes.

The following information will be used for accuracy in medical documentation. For any questions you'd prefer not to answer, please select "I'd rather not say" or write in "N/A."
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1. Please describe the history of your present condition. This includes any symptoms and their duration, onset, and progression. Please include any treatment for this issue you have already tried.
What is your legal name and what is your preferred name? *
What is your date of birth? *
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2. Are you experiencing any of the following symptoms:
7. Are you currently experiencing any of the following symptoms:
8. Please list any prescription medications you are currently taking, including dosage and frequency:
9. Please list any over the counter medications you are currently taking, including dosage and frequency:
10. Please describe your current exercise routine or any recreational activities.
11. What is/are your occupation and/or life role(s)? How many hours per day and per week? What does a usual day look like for you?
12. Have you had any diagnostic imaging done? (i.e. x-ray, MRI, defecography, ultrasound)
13. What are your goals for physical therapy? 
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