PELVIC FLOOR CONSENT

I acknowledge and understand that I have been referred for a pelvic floor and core screening. Pelvic floor dysfunctions include, but are not limited to: urinary or fecal incontinence, difficulty with bowel, bladder, or sexual functions, painful scars after childbirth or surgery, persistent pubic, sacroiliac, or low back pain, diastasis recti, or pelvic pain conditions.

I understand that to evaluate my condition it may be necessary, initially and
periodically, to have my physical therapist perform an internal pelvic floor muscle
examination. This examination is performed by observing and/or palpating the
perineal region including the vagina and/or rectum. This evaluation will assess skin condition, reflexes, muscle tone, length, strength, endurance, scar mobility, and function of the pelvic floor region.

I understand that treatment may include, but not be limited to, the following:
observation, palpation, heat, cold, stretching and strengthening exercises, soft
tissue and/or joint mobilization, and patient and/or family education.

I understand that I may experience an increase in my current level of pain or
discomfort, or an aggravation of my symptoms. The discomfort is usually
temporary; if it does not subside in 24 hours, I agree to contact my physical
therapist.

I understand that I may experience improvements including, but not limited to,
decreased pain or discomfort, increased awareness of my condition and greater
ability to manage it, increased capability of performing my daily activities and
maintaining sustained postures such as sitting, standing, etc., and/or increased
strength, endurance, range of motion, flexibility, and ease of movement. However, I understand that Angela Aitken, PT, DPT, CHN cannot make me a guarantee of a cure for or improvement in my condition.

I understand that in order for physical therapy to be effective, I must come as scheduled unless there are unusual circumstances that prevent me from attending therapy.

I agree to cooperate with and carry out the home program assigned to me.

If I have difficulty with any part of my treatment program, I will discuss it
with my physical therapist.

Thanks so much for scheduling a Pelvic Floor+Core screening with us. We will review your answers and let you know if we have any further questions. We'll text/email you to confirm our appointment the day before.

If you need to cancel or reschedule, please let us know at least 24 hours in advance so we can adjust our schedule accordingly.

Thank you and see you soon!