Medical History FormPlease complete this form prior to your first appointment at Foundational Concepts. Thanks in advance!Name* First Last Height Weight How Did You Hear About Us?* Physician/Medical Professional Family Member/Friend Website/Internet Search Instagram Facebook Issue HistoryDescribe the current problemWhen did the problem begin?Has the problem Stayed the same Gotten better Gotten worse Do you have pain with this problem? Yes No Please rate the pain 0-10(0 being no pain, 10 being the worst pain)012345678910Please describe the type of pain you are experiencing.Have you had previous treatments? Yes No Have you fallen in the last year? Yes No If you have fallen in the past year, how many times?Once2-3 timesMore than 3 timesDo you have pain with any of the following?(Please check all boxes that apply.) Pain wearing tight clothing? Pain with sitting? Pain with bowel movement? Pain with speculum exams? Pain with sexual intercourse? Pain worsens with walking? Require pain medication? Limited social outings due to pain? Pain inserting a tampon? Activities/events that cause or aggravate your symptoms.(Please check all boxes that apply.) Sitting Walking Standing Changing positions (i.e. sit to stand, etc.) Light activity (i.e. light housework) Vigorous activity/exercise (run/weight lift/jump_ Sexual activity With cough/sneeze/straining With laughing/yelling With lifting/bending With cold weather With triggers (i.e. running water/key in door) With nervousness/anxiety No activity affects the problem If you checked sitting, walking or standing on the above question, please give us more detail regarding how quickly these activities cause or aggravate your symptoms.What, if anything, relieves your symptoms? How has your lifestyle/quality of life been altered/changed because of this problem?(Check all that apply, then specify on the next line.) Social activities (exclude physical activities) Diet/Fluid intake Physical activity Work Other Please specify how any of the above have impacted your quality of life.Please rate the severity of this problem 0-10(0 being no problem, 10 being the worst)012345678910What are your treatment goals/concerns?Since the onset of your current symptoms have you had any of the following.(Please check all boxes that apply.) Fever/Chills Unexplained weight change Dizziness or fainting Change in bowel or bladder functions Malaise (unexplained tiredness) Unexplained muscle weakness Night pain/sweats Numbness/Tingling Other If you checked 'other' on the above line, please specify. Health HistoryApproximate date of last Physical Exam MM slash DD slash YYYY What, if any, tests were performed? General Health Level(Choose one of the following to describe your overall health.)ExcellentGoodAverageFairPoorWhat is your occupation? How many hours do you work per week on average?Are you currently on Disability of Leave from work? Yes No Are you on any activity restrictions at work? Yes No What is your current level of stress?HighMediumLowAre you currently under psychiatric care? Yes No What is your current activity/exercise level?None1-2 days/week3-4 days/week5+ days/weekPlease describe your exercise type/routine Have you ever had any of the following conditions or diagnoses?(Please check all that apply.) Cancer Heart Problems High Blood Pressure Ankle swelling Anemia Low Back Pain Sacroiliac/Tailbone pain Alcoholism/Drug problems Childhood bladder problems Depression Anorexia/bulimia Smoking history Vision/eye problems Hearing loss/problems Stroke Eplilepsy/seizures Multiple sclerosis Head injury Osteroporosis Chronic Fatigue Syndrome Fibromyalgia Arthritic conditions Stress fracture Rheumatoid Arthritis Joint Replacement Bone fracture Sports Injury Emphysema/chronic bronchitis Asthma Allergies (please list below) Latex sensitivity Hypothyroid/Hyperthyroid Headaches Diabetes Kidney disease Irritable Bowel Syndrome Hepatitis HIV/AIDS Sexually transmitted disease Physical or Sexual abuse Raynaud’s (cold hands and feet) Pelvic pain Other Surgical/Procedure History(Please check all that apply.) Surgery for your back/spine Surgery for your brain Surgery for your female organs Surgery for your bladder/prostate Surgery for your bones/joints Surgery for your abdominal organs Other If you checked 'other' on either of the 2 questions above, please specify. OB/GYN History (females only)(Please check all that apply.) Prolapse or organ falling out Vaginal Dryness Painful Periods Painful vaginal penetration Pelvic pain Menopause Number of Childbirth vaginal deliveriesNumber of C-SectionsNumber of Episiotomies/tearsPelvic History (males only)(Please check all that apply.) Prostate disorders Shy bladder Pelvic pain Erectile dysfunction Painful ejaculation Other If you checked 'other' on the above line, please specify. Please list all prescription medications (pills, injections, patch, etc.)(Include start date, dosing and reason for taking.)MedicationStart dateDosageReason Please list over the counter medications(Include start date, dosing and reason for taking.)MedicationStart dateDosageReason Pelvic Symptom QuestionnaireBladder / Bowel Habits / Problems(Please check all that apply.) Trouble initiating urine stream Urinary intermittent/slow stream Trouble emptying bladder Difficulty stopping bladder completely Straining or pushing to empty bladder Dribbling after urination Constant urine leakage Pain with bowel movement Leaking of feces Abdominal pain Blood in urine Painful urination Trouble feeling bladder urge/fullness Current laxative use Trouble feeling bowel/urge/fullness Consipation/straining Trouble holding back gas Recurrent bladder infections Pain with sexual intercourse Smearing of feces in underwear Feelings of bloating or gassiness Frequency of urnination(Please indicate the number of times waking and during sleeping hours)Times per DayTimes per NightWhen you have a normal urge to urinate, how long can you delay before you have to go to the toilet?MinutesHoursNot at allThe usual amount of urine passed isSmallMediumLargeFrequency of bowel movements(Please indicate the number of times waking and during sleeping hours)Times per DayTimes per NightDo you have a regular bowel schedule? Yes No When you have an urge to have a bowel movement, how long can you delay before you have to go to the toilet?MinutesHoursNot at allIf constipation is present, please describe management techniques What is the consistency of bowel movements?HardSoft solidSoft not so solidWhat is your average fluid intake?(one glass is 8 oz. or one cup)Glasses per day TotalGlasses that are CaffeinatedRate a feeling of organ "falling out" / prolapse or pelvic heaviness/pressure None present Times per month (specify below if related to activity or your period) With standing (specify length of time below) With exertion or straining Other (specify below) If you checked 'other' on the above line, or if you checked "standing" or "times per month" please specify. Bladder leakage(Please indicate the number of episodes)DailyWeeklyMonthlyOnly with exertion/coughBowel leakage(Please indicate the number of episodes)DailyWeeklyMonthlyOnly with exertion/coughOn average, how much urine do you leak?(Please check all that apply.) No leakage Just a few drops Wets underwear Wets outerwear Wets floor On average, how much stool do you lose?(Please check all that apply.) No leakage Stool staining Small amount in underwear Complete emptying Stool is formed Stool is loose What form of protection do you wear?(Please select one option.) None Minimal protection (tissue paper/paper towel/pantishield) Moderate protection (absorbant product/maxipad) Maximum protection (specialty product/diaper) Other If you checked 'other' on the above line, please specify. On average, how many pad/protection changes are required in 24 hours?(Please list number of pads)