Postnatal (up to a year) Pelvic Health Self Assessment Form

About you

Please do not continue with this form and contact your GP if:

You are losing weight for no reason
You are feeling generally unwell or feverish
You have recently become unsteady on your feet
You have suddenly noticed weakness in any of your muscles, for example you struggle to lift your foot off the floor due to weakness (not pain)

Please do not continue with this form and call NHS 111 if:
You have recently or suddenly developed lower back pain and/or leg pain AND have any of the following symptoms:

A change in your bladder function or bowel control (specifically, unable to urinate or bowel incontinence)
A change in sensation around your genitals or back passage
Loss of sexual function

These symptoms are a possible sign of Cauda Equina Syndrome. This is a condition that requires urgent medical attention. For further information, please read our Cauda Equina Information Card.

Please confirm that you have read and understood the information above Required

I confirm that I have read and understood the above

Patient Details

First name Required

Surname Required

NHS number Required

You can find this on the NHS App.

This can also be found on any letter from the NHS like a prescription or appointment letter.

You can also use the following link: https://www.nhs.uk/nhs-services/online-services/find-nhs-number/.

Date of birth Required

Europe/London

Address Required

Address 1

Address 2

City

Country

County

Postal Code

GP Details

Your GP details Required

Address 1

Address 2

City

Country

County

Postal Code

Contact details

Please make sure the contact details given are accurate as we will be relying on these to get in touch about arranging an appointment or to find out more information.

Preferred telephone number Required

Second telephone number Required

Email address Required

Please note this may be used by a physiotherapist to send information relating to your treatment.

Postnatal Self Assessment Form

Please give the date of the birth of your baby Required

Europe/London

Was your most recent pregnancy a multiple pregnancy? (e.g. twins/triplets/quadruplets) Required

None

Yes

Was your most recent pregnancy a multiple pregnancy? (e.g. twins/triplets/quadruplets) Required

None

Yes

The 'pushing' stage of labour is when the baby is actively pushed out. It starts when the cervix is fully open, and ends when the baby is born. During the birth of your baby, did you push for over 1½ hours? Required

Did you have a birth with forceps or birth with ventouse to help deliver your baby? Required

During the birth of your baby, did you have problems delivering the shoulders of your baby that required medical help? Required

During the birth of your baby, did you have a tear or cut (episiotomy) to your vagina, vulva or perineum? Required

If you had a tear from your vagina, do you know the extent of the tear? Required

Since the birth of your baby, have you had any new pelvic floor symptoms affecting your bladder or bowel? Required

How much does this bother you? Please select a number between 0 (not at all) and 10 (a great deal) Required

Since the birth of your baby, have you had a dragging feeling or bulge of the vagina? Required

Never

Sometimes

Often

Most of the time

All of the time

How much does this bother you? Please select a number between 0 (not at all) and 10 (a great deal) Required

Since the birth of your baby have you experienced pain in the pelvis, hips or lower spine? Required

Never

Sometimes

Often

Most of the time

All of the time

How much does this bother you? Please select a number between 0 (not at all) and 10 (a great deal) Required

Please select the main reason you are seeking physiotherapy: Required

Urinary incontinence or urgency

Bowel incontinence or urgency

Genital or pelvic pain

Pain or difficulty with sexual intercourse

Pelvic organ prolapse

Postnatal (up to one year) back, hip or pelvic girdle pain

Perineal trauma in delivery

General postnatal advice (including stomach & pelvic floor muscles) (up to one year)

Other

If other, please describe below

Type of delivery (select all that apply) Required

Planned Caesarean section

Unplanned Caesarean section

Vaginal Delivery Episiotomy (cut)

Forceps

Ventouse

Perineal tear

Baby’s weight Required

If you are experiencing pregnancy-related or postnatal back, pelvic girdle or hip pain please complete the following questions:

Where is your pain? (select all that apply)

Back

Hip

Pelvis

Legs

If the pain is in your legs, how far down does the pain go? Do you have any pins and needles or numbness?

Yes

If yes, please state where

Any sudden changes in bowel or bladder habits? (specifically, unable to urinate or bowel incontinence)

Yes

Are there any specific exercises or activities you wish to return to?

Are you currently on any medication?

Do you have any medical conditions that we should be aware of?

Please provide any other details you think are relevant

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Postnatal (up to a year) Pelvic Health Self Assessment Form

About you

Patient Details

GP Details

Contact details

Postnatal Self Assessment Form

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