Pelvic Floor Evaluation

Patient Name:
Date:	January 20, 2055

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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

• 1 (Poor)

• 2 (Below Average)

• 3 (Average)

• 4 (Above Average)

• 5 (Excellent)

Criteria	Description	Rating
Pelvic Muscular Strength	Evaluates the ability of the patient to contract and relax the pelvic floor muscles.
Functionality	Assesses the patient's urinary and bowel control and functionality.
Integrity	Examines the presence of any prolapse, atrophy, or pain.
Sensation	Assesses the sensation in the pelvic region, including pain, numbness, or tingling.
Pelvic Floor Endurance	Measures the endurance and stamina of the pelvic floor muscles during specific exercises.
Coordination	Evaluates the coordination and synchronization of pelvic floor muscles with other muscle groups.
Overall Function	Provides an overall evaluation of pelvic floor function in daily activities and tasks.

Additional Comments:

Comments and Notes

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