Contact Information
Personal
Address
Patient History




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How has your lifestyle or quality of life been altered or changed because of this problem?




 
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Enter Menopause date


Prescription Medications
Pills, injections, patch Reason for taking: Date started:
Over the Counter Medications
Pills, injections, patch Reason for taking: Date started:
Pelvic Symptom Questionnaire
Bladder, Bowel Habits, and Symptoms


Frequency of Urination

Frequency of bowel movements


Rate a feeling of organ "falling out" / prolapse or pelvic heaviness / pressure:






Kare Physiotherapy 1682 Willow Crescent, Kelowna, BC V1Y 4K3  Fax 250.717.1009