Allied Health Pelvic Evaluation Template

Pelvic health
- Reason for consultation: Postpartum pelvic discomfort and urinary leakage
- Relevant medical history: Previous gestational diabetes
- Patient's goals and concerns: Enhance pelvic floor strength and minimize urinary leakage
Obstetric history:
- Labour and delivery details: Vaginal birth, 8 hours of labor
- Postpartum complications or interventions: Episiotomy conducted
Current symptoms:
- Urinary symptoms: Stress-related incontinence
- Urinary habits: Frequent urination
- Urinary tract infection history: None
- Urine characteristics: Clear
- Voiding patterns: Normal
- Post-void symptoms: Dribbling
Bowel habits:
- Bowel movement frequency and consistency: Daily, soft
- Abdominal discomfort or pain: Occasional bloating
- Stool characteristics: Normal
- Gastrointestinal symptoms: None
- Relevant medical conditions: None
Diet and lifestyle:
- Dietary habits: Balanced diet
- Fluid intake: 2 liters per day
- Alcohol consumption: Occasional
- Caffeine intake: 1 cup of coffee per day
Sexual health:
- Sexual activity status: Active
- Sexual discomfort or pain: Mild discomfort
- Psychological factors related to sexual health: Anxiety about pain
Mental health:
- Mood and emotional well-being: Generally positive
- Adjustment to motherhood: Well-adjusted
- Support system: Strong family support
Physical activity:
- Exercise goals and preferences: Interested in yoga and pilates
- Financial considerations for exercise: Budget for classes
- Previous postnatal exercise experience: None
Examination findings:
- Postural assessment: Slight anterior pelvic tilt
- Diastasis recti assessment: 2-finger width separation
Management plan:
1. Pelvic floor exercises and core strengthening:
   - Exercise recommendations: Kegel exercises
   - Specific exercises suggested: Pelvic tilts
   - Frequency and consistency goals: Daily
2. Sexual health:
   - Advice on returning to sexual activity: Gradual resumption
   - Recommendations for improving comfort during intercourse: Use of lubrication
   - Suggestions for scar tissue management: Gentle massage
3. Lifestyle modifications:
   - Dietary recommendations: Increase fiber intake
   - Nutritional considerations for breastfeeding and recovery: Ensure adequate protein
   - Specific dietary suggestions: Include leafy greens
4. Exercise programme:
   - Affordable and modified exercise options: Home-based yoga
   - Encouragement for current physical activity: Continue walking
   - Referral considerations for postnatal exercise classes: Local community center
5. Education:
   - Information on normal postpartum changes: Discussed
   - Advice on posture and intra-abdominal pressure management: Provided
6. Follow-up:
   - Timeframe for follow-up appointment: 6 weeks
   - Contact information for additional support: Provided
7. Referrals:
   - Consideration for referral to other healthcare providers: Physiotherapist
(Note: Patient encouraged to reach out with any concerns or questions.)