Hollis Herman DPT, PT, IF, OCS, WCS, BCB-PMD
Doctor of Physical Therapy | Women's and Men's Health
Board Certified Orthopedic, Women’s Health, Biofeedback Specialist, ISSWSH Fellow
675 Massachusetts Ave. 5th Fl. | Cambridge, MA 02139
p. 617-576-3204 | f. 1-617-497-1565 | contact@hollyherman.com
PELVIC EVALUATION – PAGE 1
PLEASE FILL OUT and BRING WITH YOU to your first appointment (submitting electronically is also acceptable).
PATIENT NAME:
DATE:
ADDRESS:
DATE OF BIRTH:
OCCUPATION:
AGE:
DR/REFERRAL:
CHIEF COMPLAINT:
DIAGNOSIS:
DATE OF LAST PELVIC/PROSTATE EXAM:
DATE OF URINALYSIS:
RESULTS:
Neg
Pos
BLADDER
WAS THERE AN EVENT ASSOCIATED WITH ONSET OF URINARY COMPLAINTS?:
URINE STREAM:
EMPTYING:
Easy to Start
Complete
Strong
Incomplete
Weak
FREQUENCY OF URINATION: During awake hours?
URINARY SENSATION PRESENT:
Starts & Stops
Pushing or straining needed
Yes
Variable
WHAT IS THE AVERAGE VOLUME OF URINATION?:
1-4oz
Yes
During Sleep Hours?
# times per night
8-16oz
minutes,
hours
FLUID INTAKE: # of 8 oz glasses per day
HOW MANY CUPS OF TEA/COFFEE PER DAY?
CAN YOU STOP YOUR URINE ONCE STARTED?:
PAIN WITH URINATION?:
Deflects to one side
CAN YOU HOLD BACK YOUR URINE?:
4-8oz
HOW MANY OUNCES PER DAY IS WATER?:
Yes. Please describe:
Other
# times per day
No
None
Complete
Deflects
No
Unable
OTHER:
None
ANY DRIBBLING AFTER URINATION?:
Yes. Explain::
Yes
No
BOWEL
WAS THERE AN EVENT ASSOCIATED WITH ONSET OF BOWEL COMPLAINTS?:
BOWEL SENSATION PRESENT?:
Yes
No
FREQUENCY OF BOWEL MOVEMENTS:
EVACUATION HABITS:
LAXATIVE USE:
None
None
Variable
# times per day,
Straining
Splinting
None
Yes. Please describe:
CAN YOU HOLD BACK YOUR FECES IF NO BATHROOM IS AROUND?:
minutes,
hours
# times per week
Other Explain:
Yes. How often per week?
ANY BLOOD ON TISSUE AFTER BOWEL MOVEMENT?:
Yes
URINARY INCONTINENCE SYMPTOMS
URINARY LEAKAGE:
CAUSE:
None
# episodes per
Day
Week
Month
Yes. Explain:
URINE LEAKAGE AMOUNT:
DO YOU WEAR A PAD?:
None
No
Few Drops
Yes
Wets Pad
Wets Underwear
What kind?:
Wets Outerwear
# PAD CHANGES REQUIRED IN 24 HOURS:
FECAL INCONTINENCE SYMPTOMS
FECAL LEAKAGE:
# episodes per
FECAL LEAKAGE AMOUNT:
FORM OF PROTECTION:
KC4HL PELVIC EVALUATION 10/30/2010
None
None
Day
Smear
Week
Month
Diarrhea
Yes. What type of pad?:
CAUSE:
Few “Pebbles”
None
Yes. Explain:
Full Stool
# PAD CHANGES REQUIRED IN 24 HOURS:
PAGE 1 of 2
No
Hollis Herman DPT, PT, IF, OCS, WCS, BCB-PMD
Doctor of Physical Therapy | Women's and Men's Health
Board Certified Orthopedic, Women’s Health, Biofeedback Specialist, ISSWSH Fellow
675 Massachusetts Ave. 5th Fl. | Cambridge, MA 02139
p. 617-576-3204 | f. 1-617-497-1565 | contact@hollyherman.com
PELVIC EVALUATION – PAGE 2
DATE OF BIRTH:
PATIENT NAME:
DATE:
PAIN
DESCRIPTION:
None
Yes. Type of pain?:
HOW IS PAIN AFFECTED BY:
MOVEMENT:
Unaffected
REST:
Unaffected
TIME OF DAY:
Stabbing
Unaffected
Increase
BOWEL MOVEMENT:
Unaffected
VAGINAL PENETRATION:
INITIAL PENETRATION:
DEEP PENETRATION:
Increase
Unaffected
N/A
Decrease
Decrease
Increase Duration
Decrease Duration
N/A
2 Pain interrupts or prevents completion
N/A
N/A
Unaffected
Unaffected
N/A
EXERCISE:
Decrease Duration:
Increase
Unaffected
1 Discomfort that does not affect completion
LIFTING:
Decrease
Decrease
Decrease
Increase
Unaffected
0 No problems
BENDING:
Increase
Increase
Decrease
MARINOFF SCALE – DESCRIPTIVE SCALE OF INTERCOURSE
MENSTRUATION:
NIGHTTIME:
Increase Duration:
Unaffected
N/A
FOLLOWING PENETRATION:
AFTERNOON:
Decrease
Decrease
Increase
N/A
Sharp
Decrease
Unaffected
N/A
Prickling
Decrease
Increase
AFTER A BOWEL MOVEMENT:
Decrease
Increase
Increase
Increase
Unaffected
Burning
Decrease Type:
MORNING:
Unaffected
BOWEL URGE:
Sore
Decrease Type of movement?:
Increase Type:
EVENING:
URINATION:
Tender
Increase Type of movement?:
Unaffected
FULL BLADDER:
Aching
Unaffected
N/A
Increase
Increase
Unaffected
CONTACT WITH CLOTHING:
3 Pain preventing any attempts at intercourse
Increase Duration
Decrease
Decrease
Increase
Unaffected
Decrease Duration
Decrease
Increase
HOW BAD IS YOUR PAIN (10 BEING WORST)?: At best?:
Decrease
/10
At present?:
/10
At worst?:
/10
WHAT MAKES YOUR SYMPTONS WORSE?
LIFESTYLE / QUALITY OF LIFE / FUNCTIONAL LIMITATIONS
SOCIAL ACTIVITIES:
Unaffected
Yes. Explain:
DIET/FLUID INTAKE:
Unaffected
Yes. Explain:
PHYSICAL ACTIVITY:
WORK:
N/A
OTHER (SPECIFY):
Unaffected
Unaffected
N/A
Yes. Explain:
Yes. Explain:
Yes. Explain:
PATIENT GOALS:
KC4HL PELVIC EVALUATION 10/30/2010
PAGE 2 of 2