Free Pelvic Floor Evaluation Template
Pelvic Floor Evaluation
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Patient Name: |
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Date: |
January 20, 2055 |
Purpose
The purpose of this evaluation is to comprehensively assess the strength, function, and integrity of the pelvic floor muscles, ligaments, and connective tissues.
Overview
This evaluation form consists of several criteria designed to assess different aspects of pelvic floor health, including muscular strength, functionality, integrity, sensation, pelvic floor endurance, coordination, and overall function.
Instructions
Please complete each assessment or test as instructed by your healthcare provider and record your results in the evaluation table provided. Use a scale of 1 to 5, where 1 indicates poor and 5 indicates excellent.
Rating Scale
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1 (Poor)
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2 (Below Average)
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3 (Average)
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4 (Above Average)
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5 (Excellent)
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Criteria |
Description |
Rating |
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Pelvic Muscular Strength |
Evaluates the ability of the patient to contract and relax the pelvic floor muscles. |
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Functionality |
Assesses the patient's urinary and bowel control and functionality. |
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Integrity |
Examines the presence of any prolapse, atrophy, or pain. |
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Sensation |
Assesses the sensation in the pelvic region, including pain, numbness, or tingling. |
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Pelvic Floor Endurance |
Measures the endurance and stamina of the pelvic floor muscles during specific exercises. |
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Coordination |
Evaluates the coordination and synchronization of pelvic floor muscles with other muscle groups. |
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Overall Function |
Provides an overall evaluation of pelvic floor function in daily activities and tasks. |
Additional Comments:
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Comments and Notes |
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