Pregnancy and after delivery physiotherapy Pregnancy and after delivery physiotherapy "*(Required)" indicates required fields Step 1 of 5 20% If you have any vaginal bleeding or fluid loss, reduced baby movements or your baby is not moving as normal, please contact Maternity Advice Line on 0300 369 0388 The Specialist Pelvic Health Physiotherapy Team can treat Pregnancy-related and after delivery back pain, pelvic pain, hand numbness/pins and needles, postnatal separation of the tummy muscles and pelvic floor problems such as bladder and bowel leaking, feeling of vaginal prolapse such as bulging and heaviness, and pelvic floor muscle weakness. Please only complete this form if you are pregnant or are 12 months post-delivery – please see your GP for referral outside this timeframe. A rare but serious back condition, Cauda equina syndrome, can affect the nerves in the spine supplying the bladder, bowel and sexual function. The following symptoms are common during pregnancy and post-natal, but can very rarely, mean something more serious such as Cauda Equina Syndrome. It is important to share this with you. Loss of feelings/ pins and needles between your inner thighs or genitals Numbness in or around your back passage or buttocks Altered feeling when using toilet paper to wipe yourself Not knowing when your bladder is either full or empty Increasing difficulty when you are trying to urinate that is not normal for you Increasing difficulty when you try to stop or control your flow of urine that is not normal for you Loss of sensation when you pass urine ( when you wee/pee) Leaking urine or recent need to use pads that is not normal for you Inability to stop a bowel movement or leaking that is not normal for you Loss of sensation when you pass a bowel movement (have a poo) Change in ability to climax, feel internal sensation if female, or if male, to achieve an erection or ejaculate Loss of sensation in genitals during sexual intercourse (Is this same as above?) If you have back and/or leg pain and have any new symptoms listed above or noticed they have become worse in the past 14 days, seek help immediately at your local A&E department. Identification and subsequent urgent action is required to avoid permanent damage.Personal DetailsName*(Required)Date of birth*(Required) DD slash MM slash YYYY NHS Number*(Required)Find your NHS numberAre you registered with a GP?*(Required) Yes No Please tell us your GPs name and address including postcode.*(Required)You have said that you do not have a GP. Would you like to provide us with more information?Tell us more:At which hospital would you prefer to receive any physiotherapy appointments, if needed?*(Required) Dorchester Shaftsbury Westminster Memorial Hospital Bournemouth site at University Hospitals Dorset You may receive some specialist pelvic health physiotherapy as part of a workshop at either Poole or Christchurch hospital, please indicate which site is your preference. Individual appointments will be at Royal Bournemouth Hospital. We will write to you or send you a text message to let you know the location and type of appointment after your referral has been reviewed by a member of the physio team. Please select preferred site: Preferred physiotherapy*(Required) Poole Christchurch Your Address*(Required) Street Address Address Line 2 Town Postal Code Do you have a telephone number?*(Required) I do have a telephone number I do not have a telephone number Preferred telephone number:*(Required)May we leave a voicemail?*(Required) Yes No Are you happy to be contacted by email?Select "Yes" if you are happy for us to contact you via email OR if you would like a copy of this form sent to your email once submitted. Yes No Would you like a copy of this completed form sent to your email? Yes No Please enter your email:*(Required) Is someone helping you fill in this form? Yes No Please provide details of who is helping you fill in the form:Have you attended the physio antenatal back group previously?This may have been a virtual (online) or in person session led by a NHS physiotherapy team member. Yes No Where have you attended the physio antenatal back group previously?Would you like to attend a physio antenatal back group? Yes No Are you Antenatal or postnatal? Antenatal Postnatal Are you already under the care of the Physiotherapy team and wanting to get back in touch?*(Required) Yes No Please help us to provide information about the physio team whose care you are under in the final box of the form.Are you a health professional filling in this form? Yes No If you are a member of staff referring on behalf of a patient, please give us the following details:Your nameYour roleYour contact detailsAntenatalWhen is your baby due?*(Required) DD slash MM slash YYYY How many weeks pregnant are you?This field is hidden when viewing the formPlease tick the symptoms you have: Signed off work due to pain Unable to care for children due to symptoms My sleep is disrupted by the pain every night Pain at front of pelvis Pelvic floor/bladder issues Unable to walk due to pain Pain in the ribs or between shoulder blades Numb or tingling fingers My sleep is disrupted by pain Numbness elsewhere Low back pain Hip pain Leg pain Buttock pain Please state the year(s) of your previous births if this is not your first pregnancyWhere are you booked to give birth? Bournemouth Dorchester Home Other If you choose 'other' please specify details below.Type of care? Midwife led Consultant care Don't know Please tell us why:Please briefly explain why you are under a consultant thank you.PostnatalWhen did you give birth?*(Required) DD slash MM slash YYYY Where did you give birth? Bournemouth Dorchester Home Other What sort of birth did you have? Caesarean Vaginal Forceps Ventouse Breech Did you experience the following Stitches Episiotomy Tear What type of tear First Degree Second Degree Third Degree Fourth Degree How much did your baby weigh? SymptomsIf you have any vaginal bleeding or fluid loss, reduced baby movements or your baby is not moving as normal, please contact Maternity Advice Line on 0300 369 0388 Within this section, we ask you questions regarding your symptoms and pain. Please be as honest as possible so we can get you the help you need. Call NHS 111 if you think you need medical help right now. They will direct you to the best place to get help if you cannot contact your GP during the day, or when your GP is closed (out-of-hours). If you are in a life-threatening emergency, call 999.Please give a brief description of what the main problem is.*(Required)How long have you had this problem?*(Required)Less than 1 week1-2 weeks3-6 weeks7-12 weeks13 weeks - 6 months7 months - 12 monthsMore than 1 year Symptoms continuedAre you unable to walk due to pain?*(Required) Yes No Unable to walk due to pain: Everyday Sometimes Other If you choose 'other' please specify details below.Are you unable to care for children or other dependants due to symptoms?*(Required) Yes No Please tell us more.*(Required)Is your sleep is disrupted by the pain?*(Required) Yes No N/A My sleep is disrupted by the pain:*(Required) Everynight Sometimes Pain when rolling over or getting in/out of bed Do you have pain at the front of your pelvis? Yes No N/A The pain at the front of my pelvis: Comes and goes a few times a week Comes and goes every day Constant and does not settle Other If you choose 'other' please specify details below.Score the intensity out of 10 (where 0 is no pain and 10 is worst imaginable pain)Do you have lower back pain? Yes No N/A My lower back pain Comes and goes a few times a week Comes and goes every day Constant and does not settle Other Has your lower back pain been getting worse in the last 2 weeks? Yes No If you choose 'other' please specify details below.Score the intensity out of 10 (where 0 is no pain and 10 is worst imaginable pain)Do you have leg pain?Leg pain is pain that is felt below the knee. Yes No N/A My leg pain is: In one leg In both legs My leg pain: Comes and goes a few times a week Comes and goes every day Constant and does not settle Other If you choose 'other' please specify details below.Has your leg pain been getting worse in the last 2 weeks? Yes No Score the intensity out of 10 (where 0 is no pain and 10 is worst imaginable pain)Do you have hip pain? Yes No N/A My hip pain Mainly only at night Comes and goes a few times a week Comes and goes every day Is constant and does not settle Other If you choose 'other' please specify details below.Score the intensity out of 10 (where 0 is no pain and 10 is worst imaginable pain) Symptoms continued..Do you have pain in the buttock area? Yes No N/A My buttock pain: Comes and goes a few times a week Comes and goes every day Constant and does not settle Other If you choose 'other' please specify details below.Score the intensity out of 10 (where 0 is no pain and 10 is worst imaginable pain)Do you have numbness or tingling in your fingers? Yes No N/A The numbness or tingling in my fingers: Comes and goes most days Comes and goes every day Constant and does not settle Other If you choose 'other' please specify details below.Do you have numbness or tingling in your legs and feet? Yes No N/A The numb or tingling in my legs and feet: Comes and goes most days Comes and goes every day Constant and does not settle Other If you choose 'other' please specify details below.Numbness or tingling elsewhere? Please state whereDo you have pain in the ribs or between the shoulder blades? Yes No N/A The pain in the ribs or between the shoulder blades: Comes and goes most days Comes and goes every day Constant and does not settle Other If you choose 'other' please specify details below.Score the intensity out of 10 (where 0 is no pain and 10 is worst imaginable pain)Do you have any of the following pelvic floor, bladder or bowel issues?*(Required) Bladder issues Bowel issues Pelvic organ prolapse (vaginal prolapse symptoms such as bulging, heaviness, dragging) Pelvic floor muscle concerns N/A Please provide more details:*(Required)Are you unable to care for children or other dependants due to symptoms?*(Required) Yes No Please tell us more*(Required)Have you noticed any loss of feeling, or numbness in or around back passage or buttocks or pins and needles between upper thighs and genitals?*(Required) Yes No N/A Not sure Please provide more details:*(Required)Please tell us a little about your pelvic floor, bladder or bowel symptoms, or use the box below if you have any symptoms not listed on this form.This field is hidden when viewing the formAre your symptoms…? (Please tick as appropriate) Present all the time, even at rest Present with certain movements/activities Do you have any relevant pre-existing problems (please explain below) Other useful informationPlease include any pregnancy (or postnatal) related problems. e.g. a history of miscarriage, gestational diabetes, high or low blood pressure, gynae history etc.Do you have a disability or other needs that might make it more difficult for you to access to a group? i.e. hearing impairment?Do you need an interpreter and if so which language?NoYesPlease tell us what language:*(Required)Do you have a disability or other need which might make it difficult to access treatment - including attending a group - either online or face to face?YesNoPlease explain how we can may help meet your needs?When you submit the form it will go to the Physio department that you chose at the start of this form.This field is hidden when viewing the formUntitled First Choice Second Choice Third Choice
