Pelvic Floor Physical Therapy Intake

Pelvic Floor Physical Therapy Intake — Form Fields

This healthcare template includes 14 fields. Intake form for patients beginning pelvic floor physical therapy treatment. Free to customize and use on ZenBuild.

• Full Name (text, required)
• Date of Birth (text, required)
• Email (email, required)
• Phone Number (text, required)
• Primary Concern (dropdown selection, required) — options: Urinary Incontinence, Pelvic Pain, Postpartum Recovery, Prolapse, Painful Intercourse, Constipation, Pre-Surgery Preparation, Post-Surgery Rehabilitation
• How Long Have You Experienced Symptoms (dropdown selection, required) — options: Less Than 3 Months, 3-6 Months, 6-12 Months, 1-2 Years, 2+ Years
• Currently Pregnant (multiple choice, required) — options: Yes, No
• Number of Pregnancies (number, optional)
• Number of Births (number, optional)
• Delivery Type (most recent) (dropdown selection, optional) — options: Vaginal, C-Section, N/A
• Referring Physician (text, optional)
• Current Medications (text, optional)
• Symptom Description (long text, required)
• Goals for Therapy (long text, optional)