Name: Date:

Clinical History
Previous perineal rehabilitation:
 No
 Yes date: practician:
o Manual
o Stimulation
o Biofeedback
o Therapeutic education
o Life style
Results:  very good,  good,  medium,  bad
Medics:  anticholinergics, Others: ……………………..
Local treatment:
 pessary,
 vaginal tampon,
 trophicity treatment,
 Ureteral obstructor
Surgery:
 TVT TOT,
 prolapsus,
 artificial sphincter,
 neuromodulation

Medical assessment
Chief complains
 Stress incontinence  Digestive pathology
 Urge incontinence  Urodynamic assessment:
 Prolapsus o inefficient sphincter,
 Pre surgery o urethral instability,
 Post-surgery o bladder instability
 Post-partum  Child
 Sexology

Age:
Life Habits:
 Occupation:  Alcohol
 Sport:  Lumbar belt
 Tabacco  Independent/dependent

Factors
 Weight/height:
 Diabetes
 Constipation
 Hemorrhoids
 Spasmophilia
 Hyperthyroid
 Chronic bronchitis/asthma
 Hypertension
 Psychological disease or treatment
 Nephrological disease
 Urological disease:
o urinary infection,
o malformation,
o enuresis
 Neurological disease:
o multiple sclerosis,
o head/spinal injury,
o stroke,
o hemiplegia,
o Parkinson disease
 Rheumatological disease:
o low back pain,
o discopathy,
o lumbar spinal stenosis,
 Surgery:
o TVT or TOT,
o post chemotherapy,
o prolapsus