• Medical History Form

  • Please complete this form prior to your first appointment at Foundational Concepts. Thanks in advance!
  • Issue History

  • (0 being no pain, 10 being the worst pain)
  • (Please check all boxes that apply.)
  • (Please check all boxes that apply.)
  • (Check all that apply, then specify on the next line.)
  • (0 being no problem, 10 being the worst)
  • (Please check all boxes that apply.)
  • Health History

  • (Choose one of the following to describe your overall health.)
  • (Please check all that apply.)
  • (Please check all that apply.)
  • (Please check all that apply.)
  • (Please check all that apply.)
  • (Include start date, dosing and reason for taking.)
    MedicationStart dateDosageReason 
    Add a new row
  • (Include start date, dosing and reason for taking.)
    MedicationStart dateDosageReason 
    Add a new row
  • Pelvic Symptom Questionnaire

  • (Please check all that apply.)
  • (Please indicate the number of times waking and during sleeping hours)
    Times per DayTimes per Night
  • (Please indicate the number of times waking and during sleeping hours)
    Times per DayTimes per Night
  • (one glass is 8 oz. or one cup)
    Glasses per day TotalGlasses that are Caffeinated
  • (Please indicate the number of episodes)
    DailyWeeklyMonthlyOnly with exertion/cough
  • (Please indicate the number of episodes)
    DailyWeeklyMonthlyOnly with exertion/cough
  • (Please check all that apply.)
  • (Please check all that apply.)
  • (Please select one option.)
  • (Please list number of pads)