PHYSIOTHERAPY ASSESSMENT

FOR GYNECOLOGY AND OBSTETRICS

Patient name _____________________________ Date______________________

Age ____________ Occupation ___________________ Weight _____________

Consultant ______________________Marital Status ____________

Contact# _____________

If married than Duration of Marriage ____________Socioeconomic status ______________

CHIEF COMPLAINT AND DURATION:

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MODE OF DELIVERY:
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ANY OTHER SURGICAL PROCEDURE:

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HISTORY OF PRESENT ILLNESS​:

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MEDICAL HISTORY:

HTN ____, DM ____, Resp ____, Cardiac ____, Stress incontinence ___, Back pain ___ or

any other complain:

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MENSTRUAL HISTORY:

Age at menarche: Last menstrual period: Cycle length:

Duration of flow: Amount of flow: Dysmenorrhea:
Relieving measures:

OBSTETRIC AND GYNE HISTORY:

Gravida (Yes / No) Primi-gravida Para No of pregnancies

No of vaginal deliveries No of cesarean deliveries Number of living
children
Any postnatal problems -depression Number of episiotomies
Miscarriages/terminations Conception difficulties/sub fertility Score G ___ P ___

Any trouble healing after delivery Y N

History of sexual abuse or trauma Y N
Frequent urinary tract infections Y N

URINARY SYMPTOMS​:

Leakage _____, Cloudiness, ____, Haematuria _____, Hesitancy_____, Dysuria ______

Frequency ______, Stress or urge incontinence ______, Others_____________________.

CONTRACEPTION:

Current method; satisfied with method?

Previous methods______________,
Complications ________________________________
Reasons discontinued _________________________________

HEALTH MAINTENANCE:

Tobacco, alcohol, illicit drug use

Diet _________________________________
Calcium and folate intake ___________
Exercise _____________________________
Dates and results of screening tests
_____________________________________
_____________________________________
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Immunizations and dates administered
______________________________________
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PAIN:

Do you have pain with?

Sexual intercourse ​◻​ Y ​◻​ N
Pelvic exam ​◻​ Y ​◻​ N
Tampon use ​◻​ Y ​◻​ N
Back, leg, groin, abdominal pain ​◻​ Y ​◻​ N

Has your physician placed you on any restrictions? (for example: lifting, exercise,
weight bearing, braces, diet or thin liquids, etc.)

Please List___________________________________________________________________
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_____________________________________________________________________________
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OBJECTIVE ASSESMENT

PHYSICAL EXAMINATION:

Vitals: B.P ______ R.R _____ Pulse ______ Temp ________

MUSCULOSKELETAL SYSTEM ASSESSMENT

Posture: _____________________ Gait: ______________________

INVESTIGATION:
Ultrasound:
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Blood tests:
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Recent Beta Hcg Result:

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Cervical and vaginal cytology: Most recent Pap smear result ____________________________

STRENGTH OF PELVIC FLOOR

Kegel assessment​ :
0=no movement palpable
1=minimal or very small muscle bulging on palpable
3=definite muscle movements up to half range
4=firm muscle movement closing around finger half to three quarter
5=very firm muscle pull which compresses finger, full range and strong hold.

Vaginal Palpation

Pelvic Floor muscle dysfunction: non-contracting PFM non-relaxing PFM

Non-contracting, non-relaxing PFM

PFM condition underactive PFM overactive PFM non-functioning PFM

Rehabilitation potential: excellent good fair poor

Symptoms of abuse: absent present ___________________________________

Learning barriers: absent present ___________________________________

Obstacles to rehabilitation: __________________________________________________

STOP TEST:
____________________________________________________________________

DIASTASIS ASSESSMENT:
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_____________________________________________________________________________.
ASSESSMENT / ANALYSIS:
CLINICAL PROBLEM LIST:
Muscle spasm ___________________________
__________________________________
Abdominal / perineal scar adhesion __________
Poor trunk stability
Decreased PFM strength
Decreased PFM endurance ___ seconds
PFM trigger point / pain _________________
Increased PFM resting tone ________________
Increased tissue laxity: anterior, posterior, urethra
Increased overflow with PFM contraction
Decreased relaxation ability
Decreased involuntary contraction / relaxation
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FUNCTIONAL PROBLEM
Decreased sexual activity due to pain
pain
Decreased tolerance for vaginal penetration
10 pain
Limited social activities due to UI or pain
pain
Decreased sitting ability Min
travel, social
Decreased standing ability Min
social
Decreased sleeping ability pain
Decreased walking distance minutes / miles
Decreased ability for basic ADLs leakage/ pain
%
Decreased ability for advanced ADLs leakage/pain
____ % ↓ Decreased tolerance for work
Urinary frequency
Poor knowledge of PFM contraction
Poor knowledge of PFM relaxation
Poor knowledge of posture and body mechanics
Good knowledge of posture and body mechanics
CLINICAL GOALS:
Normalize scar mobility
Improve trunk stability
PFM strength: normal, strong
PFM contractions hold with good quality
Decrease PFM pain
Normalize PFM tone
Improved support of the PFM
Good isolation of PFM
Improved relaxation ability
Improved involuntary contraction/relaxation
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LIST FUNCTIONAL GOALS
Resume sexual activity with ____ / 10
Able to insert # ___ dilator with ___ /
Social activity not limited by UI or
Sitting ability minutes for work,
Standing minutes for work, home
Sleeping hours per night
Walking minutes / miles
Basic ADLs with ___ /10 pain / ___
Advanced ADLs with ___ /10 pain /
Able to tolerate hour work day
___ hour voiding schedule
Good knowledge of PFM contraction
Good knowledge of PFM relaxation
Poor knowledge of self-help _____________________________
Good knowledge of self-help ____________________________
Initial functional index / QOL score ___________________________________________
Discharge functional index / QOLscore _________________________________________

PHYSIOTHERAPY MANAGEMENT:

TREATMENT PLAN:

Frequency: ________________ Duration: ___________________

Neuromuscular reeducation:
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Therapeutic exercise: _________________________________________________________
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Manual therapy: _____________________________________________________________
___________________________________________________________________________
Therapeutic activities:
___________________________________________________________________________
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Modalities: _________________________________________________________________
Other: _____________________________________________________________________
Bladder training and fluid education:
_____________________________________________________________________________
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REFLECTION:

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 Physiotherapist signature:

DAY 1 TREATMENT PROTOCOL:

DAY 2 TREATMENT PROTOCOL:

HOME PLAN:

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