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  • Health Questionairre & Consent Forms

    We are thrilled 💖 you have chosen to partner with us on your healing journey 🙏.

    Completing this secure HIPPA protected form prior to your first appointment helps us focus on you and getting you better, faster.

    * = required field

  • PATIENT INFORMATION

  • Patient Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Today Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • How Did You First Hear About Us*
  • Online Platform
  • Sex Assigned at Birth*
  • Is Your Gender Identity the Same as Your Birth Sex?
  • Utilizing Health Insurance Benefits?*
  • Format: (000) 000-0000.
  • Do You Have Secondary Insurance?*
  • Secondary Insurance Type*
  • Format: (000) 000-0000.

  • Unfortunately, we do not accept patients that have Medicaid as either their primary or secondary insurance and there are no exceptions.

    When you have two types of insurance, like Medicare and Medicaid, they must work together to make sure your medical bills get paid. So, when the cost of treatment exceeds what Medicare can pay, which is often the case, then cost sharing policy provisions kick in and we have to bill Medicaid which we don’t accept. We apologize for this inconvenience, and I wish we had better news for you. As a provider it is critical we follow certain insurance rules, otherwise we will almost certainly face legal and financial consequences that would shut the practice.

  • SYMPTOMS & GOALS:

  • Primary Reason(s) for Visit*
  • Primary Therapy Goals

  • PREGNANCY:

  • Pregnancy history (if any)
  • Approximate Due Date?
     - -
    2 digit month, 2 digit day, 4 digit year

  • Important: 

    Pregnancy:

    • 1st Trimester: We focus entirely on external assessments to keep you comfortable. No provider note is needed to get started!
    • 2nd & 3rd Trimesters: Internal assessments are a wonderful tool to prepare for birth. We can easily introduce these once your OB/GYN or midwife gives us a quick, routine clearance.

     

  • Postpartum:

    • No doctor's note needed: You are all set to come in as scheduled.
      Under 6 weeks: We focus on pain relief, comfortable movement, and newborn care ergonomics (no internal exams).
      6+ weeks: Full internal pelvic floor checks are available once you have had your routine OB/midwife visit.

  • DISCOMFORT FEEDBACK:

  • What is the pain level range - from least pain (0) to worst pain (10)?
  • Describe Pain Type (tick all that apply)
  • Exercise Habits & Routine? mode, frequency, duration

  • BLADDER:

  • Average Daily Fluid Intake (in ounces, 8fl oz = 1 cup)
  • Hours Between Emptying Your Bladder During the Day?
  • Hours Between Emptying Your Bladder During Night?
  • Number of Times You Empty During 24 Hour Period?
  • Number of Times You Get Up at Night To Empty Your Bladder?

  • BOWEL:

  • Common Stool Consistency (tick all that apply)
  • Can you fully empty your bowel?
  • Experience pain or discomfort with bowel movements?

  • SEXUAL ACTIVITY:

  • Experience Pain With Orgasm?

  • MEDICAL HISTORY:

    Check current, previous, or n/a for diagnoses

  • Rows
  • Rows

  • SURGICAL HISTORY:

    Enter Approximate Dates If Applicable. (MM / YYYY)

  • DIAGNOSTIC TESTS:

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  • MEDICATION & SUPPLEMENT HISTORY:

  • PEDIATRIC PATIENT QUESTIONS:

  • Evaluation & Treatment History (tick all that apply)

  • HOUSEKEEPING

     Arrival: Please arrive 10–15 minutes early.

    Even if your paperwork is done, our fr ont desk will quickly review the plan of care approach and booking methods/policies to enhance outcomes.

    What to wear: 

    Comfortable clothing you can move in.

    Cancellation Policy Summary: 

    Please provide advance notice if you need to reschedule so we can offer your slot to patients on our waitlist:

     

    • Tuesday – Friday Appointments: Notice required more than 24 hours in advance.
    • Monday Appointments: Notice required by 12:00 PM (Noon) the previous Friday.
    • Late Cancel / Missed Visit Fee: $90 (full details outlined in "YOUR HEALTH & $90 MISSED VISIT/LATE CANCEL POLICY" section below)

  • Menstruation: Being on your period doesn't stop us from treating you. Internal pelvic floor assessments are safe during your cycle if you're comfortable. Prefer to skip internal work? We'll focus on external evaluation and treatment instead.

  • We strongly encourage you to read the following forms as they contain IMPORTANT information about your rights, attestations and financial terms.

     

    You MUST scroll to the bottom of each form to be able to check the box.

     

    * = required field

  • PARENTAL / GUARDIAN PRESENCE IN MINOR PATIENTS TREATMENT SESSION (patient ages 15-17)*
  • Text & Email Appointment Reminders Will Be Sent Unless A Single Preference Below Is Selected (not required)
  • Reload
  • Date & Time Stamp

  • Our expert doctorate therapists look forward to seeing you soon and helping get you get back to full health.

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