Outpatient Rehabilitation Services

Pelvic Rehabilitation Patient Form

Please fill out the outpatient rehabilitation health questionnaire below before your appointment. Appointments are by referral only. Please call 401-793-2145 for additional information.

Personal Information

Describe Your Problem

Pain

Do you have pain?

Please rate your pain (0=no pain, 10=worst pain imaginable) over the past 24 hours:

Current and Recent Issues

Have you RECENTLY had any of the following problems?

Medical History

Have you been diagnosed with:

Surgical History

Tests

Allergies

Do you have any allergies?

OB/GYN History

Check all that apply:
Have you ever had ob/gyn surgery?

Check all that apply:

Are You Pregnant?

History of Previous Pregnancies

Have you been pregnant in the past?

Gynecological History

Type(s) of intercourse?
Please check if you use any of the following:

Men's Health History

Have you ever been diagnosed with any of the following? (Check all that apply.)

Additional Surgical History

Please check any of the following procedures that you have experienced:

Bladder/Bowel Habits/Problems

Check all bladder/bowel issues that apply:

Psychological History

Employment

How Do You Learn Best?

Have You Fallen Over the Past Year?

Outpatient Rehabilitation Services