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What is your main complaint you are seeking pelvic floor therapy for?
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How often does the problem occur? (check all the apply to you)
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Pain Scale
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Past Medical History (check all the apply to you)
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Type other past medical conditions here:
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Past Surgery/Gynecological/Obstetric History
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Any Allergies?
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Musculoskeletal (Any aches, joint, pains, muscle aches?)
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Gut (check all the apply to you)
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Explanation for Gut Issues
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Sleep: How many hours?
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Musculoskeletal (Any aches, joint, pains, muscle aches, injuries?)
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Medications Currently Taking: (Please include any supplements, oils or other natural medications that you are currently taking.)
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Social Context
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Social Activities/Hobbies
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Exercise
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Work
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Pain
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Describe your pain
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Rate the severity of the pain from 0 (none) - 10 (worst)
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What makes the pain better? Worse?
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Nutritional Intake
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Water Intake
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Alcohol Consumption
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Caffeine Use (Include tea, coffee, soda, caffeine pills, or green tea consumption)
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Smoking Status (Include how often and how many packs a day please)
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Fiber Intake
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Other Dietary Info
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Bladder Function
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Select bladder symptoms that you experience
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How many times do you urinate (pee) during the day and at night?
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Other
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Bowel Function
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Number of bowel movements per day/week
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Stool Consistency: You can pick more than 1
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Bowel Symptoms
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Other
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Sexual Health
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Sexual Health Symptoms
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Importance of Sexual Intimacy in your life
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Other
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Stress Level
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Seeing Mental Health Provider Yes / No
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Patient Goal for Therapy
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Severity of the Issue 0 (best)-10 (worst)
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