Call Our Number: 1-833-532-5668 FollowFollowFollowFollow PATIENT INFORMATION Please Answer if Any of The Following Apply: NameEmail:Age:Date:Are you currently pregnant?YesNoDo you have a pacemaker?YesNoImplanted defibrillator or implanted neurostimulator?YesNoElectronic implants?YesNoDrug Pump?YesNoMetal implants?YesNoMetal in Pelvis?YesNoBleeding condition?YesNoAre you on a blood thinner?YesNoDo you have an active malignancy? (cancer)YesNoAllergies:Current Medications:Past Medical History:Previous Surgeries with approximate date:Current Medical Problems: DiabetesYesNoHypertensionYesNoCoronary Artery DiseaseYesNoAsthmaYesNoChronic Obstructive Pulmonary DiseaseYesNoOtherYesNoUrinary History: Pads per day/weekLiners per day/weekDisposable underwear per day/weekDo you leak or dribble when you cough, sneeze or laugh? Yes/NoYesNoDo you leak or dribble when you are active i.e. exercising, cleaning, dancing, lifting?YesNoHow many times do you get out of bed at night to urinate?Do you have trouble getting to the bathroom in time when you have to urinate?YesNoDo you have trouble totally emptying your bladder?YesNoDoes it burn when you urinate?YesNoIs there blood in your urine?YesNoPain with urination?YesNoHow often do you urinate during the day?How much fluid do you drink during the day? (ounces)Are you constipated?YesNoFamily History:: DiabetesYesNoHigh blood PressureYesNoHeart DiseaseYesNoCancerYesNoPsychological problemsYesNoSocial History Smoking/Packs per DayYesNoSocial AlcoholYesNoReview of Systems: Blurred visionYesNoDouble visionYesNoRinging in earsYesNoDizzinessYesNoChest PainYesNoShortness of BreathYesNoCough up BloodYesNoAbdominal pain (persistent)YesNoHistory of enlarged prostateYesNoProstate CancerYesNoBlood in UrineYesNoBlack or tarry stoolsYesNoBloody stoolsYesNoRecent change in bowel habitsYesNoSeizuresYesNoPassing out spellsYesNoWeakness in arms or legsYesNoMemory LossYesNoParkinson’s DiseaseYesNoMultiple SclerosisYesNoHistory of StrokeYesNoPHYSICAL EXAM:(DO NOT FILL IN) HEENTPositiveNegativeHeartPositiveNegativeLungsPositiveNegativeAbdomenPositiveNegativeExtremitiesPositiveNegativeNeurologicalPositiveNegativeIMPRESSION: (THOSE THAT APPLY ARE CIRCLED) Stress Urinary Incontinence Urge Incontinence Mixed Incontinence Overflow Incontinence Functional Incontinence Gross total Incontinence PLAN: (THOSE THAT APPLY ARE CIRCLED) Emsella Chair –6 treatments (two times per week for three weeks) Behavioral Modification Medications Pessary Botox Surgery Will reassess results in three weeks to see if additional treatment is necessary This iframe contains the logic required to handle Ajax powered Gravity Forms.