Tinnitus

Balance

Falls Risk Assessment 

Communicable Diseases

Appointment Guideline

• If you are more than 10 minutes late, you may be asked to reschedule
• Cancellations and requests for rescheduling must be given 24 hours before the appointment time
• If you cancel more than 3 appointments or you do not show for more than 2 appointments within 10 scheduled sessions for any reason, you will automatically be removed from the therapy schedule and may be discharged. To restart therapy, you will need a new prescription from your physician.

PLEASE INFORM US IF YOU BEGIN TAKING ANY NEW MEDICATIONS DURING YOUR COURSE OF THERAPY

Tinnitus

Equilibrio

Evaluación Del Riesgo De Caídas

Enfermedades transmisibles

INFÓRMENOS SI COMIENZA A TOMAR MEDICAMENTOS NUEVOS DURANTE SU TERAPIA

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• CONSENT:  I, the above listed Patient or as the legally authorized person for the Patient, hereby consent to receiving pelvic examinations being performed by my physician or other health care practitioner,  any medical student or any student receiving training as a health care practitioner.
  

• NATURE OF PELVIC EXAMINATIONS: For the purposes of this Consent Form, a “pelvic examination” means the series of tasks that comprise an examination of the vagina, cervix, uterus, fallopian tubes, ovaries, rectum,  external pelvic tissue, or organs using any combination of modalities, which may include, but need not be limited to, the health care provider’s gloved hand or instrumentation.

• VALIDITY OF CONSENT:  The Patient, or the Patient’s legally authorized person, acknowledges that this consent will remain valid from the date the Patient, or the Patient’s legally authorized person, dated this Consent Form below, unless otherwise revoked in writing by the Patient, or the Patient’s legal authorized person.

I CONSENT TO RECEIVE PELVIC EXAMINATIONS AS DESCRIBED ABOVE, AND ALL MY QUESTIONS HAVE BEEN ANSWERED TO MY SATISFACTION.

Urinary Symptoms

Bowel Habits

How often do you have a bowel movement?  

Sexual Function

Pain

Falls Risk Assessment

Communicable Diseases

Appointment Guidelines

• If you are more than 10 minutes late, you may be asked to reschedule
• Cancellations and requests for rescheduling must be given 24 hours before the appointment time
• If you cancel more than 3 appointments or you do not show for more than 2 appointments within 10 scheduled sessions for any reason, you will automatically be removed from the therapy schedule and may be discharged. To restart therapy, you will need a new prescription from your physician.

PLEASE INFORM US IF YOU BEGIN TAKING ANY NEW MEDICATIONS DURING YOUR COURSE OF THERAPY

**************************

• CONSENT:  I, the above listed Patient or as the legally authorized person for the Patient, hereby consent to receiving pelvic examinations being performed by my physician or other health care practitioner,  any medical student or any student receiving training as a health care practitioner.
  

• NATURE OF PELVIC EXAMINATIONS: For the purposes of this Consent Form, a “pelvic examination” means the series of tasks that comprise an examination of the vagina, cervix, uterus, fallopian tubes, ovaries, rectum,  external pelvic tissue, or organs using any combination of modalities, which may include, but need not be limited to, the health care provider’s gloved hand or instrumentation.

• VALIDITY OF CONSENT:  The Patient, or the Patient’s legally authorized person, acknowledges that this consent will remain valid from the date the Patient, or the Patient’s legally authorized person, dated this Consent Form below, unless otherwise revoked in writing by the Patient, or the Patient’s legal authorized person.

I CONSENT TO RECEIVE PELVIC EXAMINATIONS AS DESCRIBED ABOVE, AND ALL MY QUESTIONS HAVE BEEN ANSWERED TO MY SATISFACTION.

Síntomas urinarios

Hábitos intestinales

¿Con qué frecuencia mueve los intestinos?

Función sexual

Dolor

Evaluación de riesgo de caídas    

Enfermedades transmisibles

Directrices de citas

* Si llega más de 10 minutos tarde, le podrían pedir que reprograme su cita

* Las cancelaciones y solicitudes de reprogramación deben realizarse 24 horas antes de la hora de la cita

* Si cancela más de 3 citas o si falta a más de 2 citas de 10 citas programadas, por el motivo que fuera, será dado de baja del cronograma

de terapia y será eliminado del cronograma de terapia y dado de alta. Para reiniciar la terapia, necesitará una nueva receta de su médico.  

INFÓRMENOS SI COMIENZA A TOMAR MEDICAMENTOS NUEVOS DURANTE SU TERAPIA

**************************

• CONSENT:  I, the above listed Patient or as the legally authorized person for the Patient, hereby consent to receiving pelvic examinations being performed by my physician or other health care practitioner,  any medical student or any student receiving training as a health care practitioner.
  

• NATURE OF PELVIC EXAMINATIONS: For the purposes of this Consent Form, a “pelvic examination” means the series of tasks that comprise an examination of the vagina, cervix, uterus, fallopian tubes, ovaries, rectum,  external pelvic tissue, or organs using any combination of modalities, which may include, but need not be limited to, the health care provider’s gloved hand or instrumentation.

• VALIDITY OF CONSENT:  The Patient, or the Patient’s legally authorized person, acknowledges that this consent will remain valid from the date the Patient, or the Patient’s legally authorized person, dated this Consent Form below, unless otherwise revoked in writing by the Patient, or the Patient’s legal authorized person.

I CONSENT TO RECEIVE PELVIC EXAMINATIONS AS DESCRIBED ABOVE, AND ALL MY QUESTIONS HAVE BEEN ANSWERED TO MY SATISFACTION.

Pelvic/Abdominal Surgical History (i.e. hysterectomy, adhesions, endometriosis, etc.)

ICIQ-UI short form:

/ 21     =  Sum scores from box A + B + C

Bowel Habits

How often do you have a bowel movement?  

Falls Risk Assessment

Communicable Diseases

Appointment Guidelines