the mama’s physio
the get-to-know-you health and wellness questionnaire
Today’s Date: Click here to enter text.
Your Name: Click here to enter text.
Address: Click here to enter text.
City: Click here to enter text.
Prov: Click here to enter text. Postal Code: Click here to enter text.
Birthdate: Click here to enter text.
Primary Phone: Click here to enter text.
Alt. Phone: Click here to enter text.
Email: Click here to enter text.
I give consent for my appointments and/or information relating to my program to be
emailed to me. YES or NO
Emergency Contact: Click here to enter text. Phone: Click here to enter text.
Relationship: Click here to enter text.
What do you do for work currently? Click here to enter text.
How did you hear about The Mama’s Physio? Click here to enter text.
Family Physician: Dr. Click here to enter text.
Phone: Click here to enter text.
Are you pregnant? YES or NO. If so, how many weeks? Click here to enter text.
How is your sleep? Click here to enter text.
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How is your mental health and/or stress levels? Click here to enter text.
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How is your nutrition? Click here to enter text.
The Mama’s Physio
A Branch of LifeSpring Physiotherapy
phone. 226-377-3933
fax. 519-937-1650
www.themamasphysio.com
the mama’s physio
Please put a star next to all that apply.
Angina
Anorexia
Blood disorder
Back Problems
Osteoarthritis
Recurrent bladder
infections
Scoliosis
High blood pressure
Ulcers
Chest pain
Cancer
Chronic cough
Fibromyalgia
Loss of bladder
control
Diabetes
Depression
Anxiety
Vision disturbances
Alcohol
dependence
Dizziness
Epilepsy
Hypo/hyperthyroid
Metal implants
Joint stiffness
Neck pain
Prostate problems
PMS
Others: Click here to enter text.
Diabetes I or II
Stroke
Edema
Neurological
disorder
Gastrointestinal
problems
Generalized pain
Breathing/lung
difficulties
Drug dependence
Kidney problems
Fainting
Pacemaker
Hepatitis
Heart disease
Headaches
Osteoporosis
HIV
Rheumatoid arthritis
Smoking - Packs/Day Click here to enter text.
Alcohol - Drinks/Week Click here to enter text.
Caffeine Drinks - Cups/Day Click here to enter text.
Water – Cups/Day Click here to enter text.
What is your height? Click here to enter text. Weight? Click here to enter text.
List past medical history with dates (injuries, fractures, hospitalizations, surgeries): Click
here to enter text.
List current medication and what it is for: Click here to enter text.
The Mama’s Physio
A Branch of LifeSpring Physiotherapy
phone. 226-377-3933
fax. 519-937-1650
www.themamasphysio.com
Page
Please list all allergies (including latex): Click here to enter text.
2
List any conditions which run in your family or which affect family members: Click here to
enter text.
the mama’s physio
Pregnancy, Labour, Delivery and Post-Partum Info
Do you have a chief complaint that has led you to seek physiotherapy care? Describe.
Click here to enter text.
List other treatments, services received or tests you’ve had for this complaint: Click here to
enter text.
History:
No. of pregnancies: Click here to enter text. No. of vaginal deliveries: Click here to enter text.
Birth weight of largest baby: Click here to enter text. No. of C-sections: Click here to enter text.
No. of miscarriages: Click here to enter text. No. of episiotomies: Click here to enter text.
Length of most recent labour (2nd stage/pushing): Click here to enter text.
Anything noteworthy during pregnancy, labour or delivery? Click here to enter text.
Have you experienced any past obstetric trauma? Click here to enter text.
Did you have any trouble healing after delivery? Click here to enter text.
Are you having regular periods/menstrual cycles? Click here to enter text.
Do you have frequent urinary tract infections? Click here to enter text.
Have you experienced abuse of any kind? (**Optional to answer) Click here to enter text.
Active
Very active
Epidural
Breech
C-section
Forceps
Episiotomy
Currently breastfeeding
Scarring
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Select all that apply:
Suction
Tearing
Light
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Select your level of activity: Sedentary
The Mama’s Physio
A Branch of LifeSpring Physiotherapy
phone. 226-377-3933
fax. 519-937-1650
www.themamasphysio.com
the mama’s physio
I notice bulging or tenting of my belly when I lift my head off a pillow or during exercise:
YES or NO
Please put a star next to the areas of pain:
Sexual intercourse –
before/during/after
Physical activity
Pubic bone
Pelvic exam or
tampon use
Groin
Pelvis
Legs
Menses
Abdominal area
Buttocks
Back
Other:
Select the difficulties you have with daily tasks and movements: Lying
Rolling over
Lie <--> Sit
Sit <-->Stand
Squatting
Forward bending
Sitting
Driving
Lifting Getting in and out of car
Carrying
Walking
Chores Other:
Test results:
Urodynamics test - Results: Click here to enter text.
Cystoscope - Results: Click here to enter text.
Urine tests - Results: Click here to enter text.
Bowel tests - Results: Click here to enter text.
Others: Click here to enter text.
Bladder Symptoms: Please put a star next to things that cause you to lose urine:
Sneezing
Jumping
Lying down
Position change
Lifting
Vomiting
Running
Intercourse
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Laughing
Dancing
Sitting
Straining
Other:
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Coughing
Exercise
Standing
Walking
Pushing
The Mama’s Physio
A Branch of LifeSpring Physiotherapy
phone. 226-377-3933
fax. 519-937-1650
www.themamasphysio.com
the mama’s physio
Checkmark the statements that apply:
☐I leak urine on the way to the bathroom.
☐I have a strong urge to urinate.
☐I leak when I hear running water.
☐I have burning and/or pain with urination.
☐I have difficulty starting a stream of urine.
☐I have difficulty stopping the flow of urine.
☐I feel the need to strain to empty my bladder.
☐I feel unable to empty my bladder fully.
☐I have a feeling of pressure, heaviness and/or bulging in my vagina or rectum.
☐I have pain with a full bladder.
☐I urinate more than 7 times a day.
☐I awaken with a strong urge to urinate. Times per night. Click here to enter text.
☐I use pads or tampons for leakage. Number per day: Click here to enter text.
Type of pad used: Click here to enter text.
Select the typical colour of your urine: Clear
Pale
Light Yellow Dark Yellow
Bowel symptoms: Checkmark the statements that apply:
Select your most common stool consistency: liquid, soft, firm, pellets, other:
The Mama’s Physio
A Branch of LifeSpring Physiotherapy
phone. 226-377-3933
fax. 519-937-1650
www.themamasphysio.com
Page
How often do you move your bowels? Click here to enter text.
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☐I strain to have a bowel movement.
☐I leak/stain feces.
☐I have diarrhea often.
☐I include fibre in my diet.
☐I take laxatives/enema regularly.
☐I leak gas by accident.
☐I have pain with bowel movement.
☐I have a very strong urge to move my bowels.
☐I have hemorrhoids.
the mama’s physio
If you’re pregnant:
What positions do you plan to use during labour and delivery: Click here to enter text.
What pain control strategies will you use during labour and delivery: Click here to enter text.
I have the following questions regarding preparing for my delivery: Click here to enter text.
My current exercise routine is: Click here to enter text.
If you’re post-partum:
What activity, sports, or fitness programs would you like to start or return to? Click here to
enter text.
Have you been diagnosed with a pelvic organ prolapse? Click here to enter text.
The last few and important questions:
How do you feel about how you currently look and function: Click here to enter text.
What questions do you have about optimizing your health during this time in your life?
Click here to enter text.
What are your expectations of your physiotherapist regarding this program? Click here to
enter text.
What are your goals and expectations of yourself regarding your participation in this
program? Click here to enter text.
Is there anything else you would like to ask about or address during your program? Click
here to enter text.
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Your Initials: Click here to enter text. Date: Click here to enter text.
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Thanks for taking the time to fill out this questionnaire! By initialling and returning this form to your physiotherapist,
you certify that all of the above information is complete and accurate to the best of your knowledge.
The Mama’s Physio
A Branch of LifeSpring Physiotherapy
phone. 226-377-3933
fax. 519-937-1650
www.themamasphysio.com