Pelvic Floor - Abilene Physical Therapy & Sports Rehab

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Pelvic Floor Dysfunction
Chapman Location

For patients experiencing incontinence, constipation, pelvic pain, or are pre/post natal. Please fill out to the best of your ability and submit.

* Indicates required field

Name *

First

Last

PLEASE RATE YOUR PAIN LEVEL WITH ACTIVITY *

0 - No Pain 1 - Minimal - hardly noticeable 2-Mild - aware of pain but don't pay attention to it 3-Uncomfortable - bothers me but I can ignore it 4-Moderate - Constantly aware but can continue most activities 5-Distracting - Constantly aware and keeping me from doing some activities 6 - Distressing - Constantly aware of pain and I give up many activities. 7-Unmanageable - In pain all the time and unable to do most activities 8-Intense - Pain is so severe that it is hard to think of anything else. Talking & listening are difficult 9-Severe - My pain is all I can think about. I can barely talk or move because of it. 10-Unable to Move - In bed and can't move due to my pain. I need to go to the emergency room.

1. Do you usually experience pressure in the lower abdomen? *

Yes No

1b. If YES, how much does it bother you? *

Not at all Somewhat Moderately Quite a bit

2. Do you usually experience heaviness or dullness in the lower abdomen? *

Yes No

2b. If YES, how much does it bother you? *

Not at all Somewhat Moderately Quite a bit

3. Do you usually have a bulge or something falling out that you can see or feel in the vaginal/rectal area? *

Yes No

3b. If YES, how much does it bother you? *

Not at all Somewhat Moderately Quite a bit

4. Do you usually have to push on the vagina or around the rectum to have a complete bowel movement? *

Yes No

4b. If YES, how much does it bother you? *

Not at all Somewhat Moderately Quite a bit

5. Do you usually experience a feeling of incomplete bladder emptying? *

Yes No

5b. If YES, how much does it bother you? *

Not at all Somewhat Moderately Qutie a bit

6. Do you ever have to push up in the vaginal/perineal area with your fingers to start or complete urination? *

Yes No

6b. If YES, how much does it bother you? *

Not at all Somewhat Moderately Quite a bit

7. Do you feel you need to strain too hard to have a bowel movement? *

Yes No

7b. If YES, how much does it bother you? *

Not at all Somewhat Moderately Quite a bit

8. Do you feel you have not completely emptied your bowels at the end of a bowel movement? *

Yes No

8b. If YES, how much does it bother you? *

Not at all Somewhat Moderately Quite a bit

9. Do you usually lose stool beyond your control if your stool is well formed? *

Yes No

9b. If YES, how much does it bother you? *

Not at all Somewhat Moderately Quite a bit

10. Do you usually lose stool beyond your control if your stool is loose or liquid? *

Yes No

10b. If YES, how much does it bother you? *

Not at all Somewhat Moderately Quite a bit

11. Do you usually lose gas from the rectum beyond your control? *

Yes No

11b. If YES, how much does it bother you? *

Not at all Somewhat Moderately Quite a bit

12. Do you usually have pain when you pass your stool? *

Yes No

12b. If YES, how much does it bother you? *

Not at all Somewhat Moderately Quite a bit

13. Do you experience a strong sense of urgency and have to rush to the bathroom to have a bowel movement? *

Yes No

13b. If YES, how much does it bother you? *

Not at all Somewhat Moderately Quite a bit

14. Does part of your stool ever pass through the rectum and bulge outside during or after a bowel movement? *

Yes No

14b. If YES, how much does it bother you? *

Not at all Somewhat Moderately Quite a bit

15. Do you usually experience frequent urination? *

Yes No

15b. If YES, how much does it bother you? *

Not at all Somewhat Moderately Quite a bit

16. Do you usually experience urine leakage associated with a feeling of urgency; that is, a strong sensation of needing to go to the bathroom? *

Yes No

16b. If YES, how much does it bother you? *

Not at all Somewhat Moderately Quite a bit

17. Do you usually experience urine leakage related to laughing, coughing, or sneezing? *

Yes No

17b. If YES, how much does it bother you? *

Not at all Somewhat Moderately Quite a bit

18. Do you usually experience small amounts of urine leakage (that is, drops)? *

Yes No

18b. If YES, how much does it bother you? *

Not at all Somewhat Moderately Quite a bit

19. Do you usually experience difficulty emptying your bladder? *

Yes No

19b. If YES, how much does it bother you? *

Not at all Somewhat Moderately Quite a bit

20. Do you usually experience pain or discomfort in the lower abdomen or genital region? *

Yes No

20b. If YES, how much does it bother you? *

Not at all Somewhat Moderately Quite a bit

Submit

The state of Kansas is a “Direct Access” state for Physical Therapy.
You can begin physical therapy with or without a referral from a physician.

Now With 2 Locations to Better Serve You!

103 Northwest 15th Street
Abilene, KS 67410
Phone: 785-263-3646
FAX: 785-263-3689

HOURS:
Monday - Friday
8:00 a.m - 5:00 p.m.

1030 North Marshall, Suite B
Chapman, KS 67431
Phone: 785-922-4016
FAX: 785-922-4018

HOURS:
Monday - 1 p.m. - 5 p.m.
Tuesday & Thursday 8 a.m. - 5 p.m.

Contact Us

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