Pelvic Floor Biofeedback Therapy Initial Evaluation

Date: [Date]

Patient Name: [Patient Name]

DOB: [DOB]

Referring Provider: [Provider name / self-referral / direct access]

Referral Diagnosis: [Diagnosis / N/A]

Care Setting: [outpatient clinic / hospital-based outpatient / home health / telehealth]

Consent and Exam Conditions

[Documentation of informed consent obtained for evaluation and specified exam components] (Specify consented components: external observation, internal vaginal exam, internal rectal exam, biofeedback sensor placement. Note that patient was informed they may pause or stop at any time.)

Chaperone: [offered and accepted / offered and declined / not offered with reason]. [Name and role if present]

Exam components performed today: [external pelvic observation / internal vaginal exam / internal rectal exam / biofeedback sensor placement] (If internal exam or sensor placement was not performed, document the reason and alternative assessment approach used.)

Chief Complaint and Presenting Concerns

[Chief complaint in patient's words when helpful, followed by brief narrative summary of presenting concerns and functional impact]

• Symptom domains addressed: [urinary symptoms / bowel symptoms / pelvic pain / prolapse symptoms]
• Patient-stated functional goals: [Functional goals]
• Key symptom descriptors: [onset/duration, severity, frequency, triggers/modifiers, impact on ADLs/QoL]

Symptom History

Urinary Symptoms

(Include if urinary symptoms are a presenting concern.)

• Daytime frequency: [# voids/day]
• Nocturia: [# voids/night]
• Urgency triggers: [triggers / none]
• Leakage: [type: stress / urgency / mixed / insensible / post-void dribble] [frequency] [circumstances]
• Pad/protective garment use: [type and quantity / none]
• Voiding/emptying symptoms: [hesitancy / intermittency / weak stream / straining / incomplete emptying / retention / post-void dribble / none]
• Red flags: [dysuria / hematuria / recurrent UTIs / retention symptoms / none] (If present, document actions taken or referral initiated.)

Bowel Symptoms

(Include if bowel symptoms are a presenting concern.)

• Stool frequency: [#/week or day]
• Stool form (Bristol): [Type # range]
• Straining: [present / absent] [degree if present]
• Incomplete evacuation: [present / absent]
• Manual maneuvers: [perineal pressure / digital evacuation / vaginal splinting / none]
• Fecal incontinence: [type: liquid / solid / gas] [frequency] [urgency-associated: yes / no] (Omit if not present.)
• Dietary factors: [fiber intake, fluid intake, caffeine, other relevant factors]
• Current bowel medications/supplements: [laxatives / stool softeners / fiber supplements / antidiarrheals / none]

Pelvic Pain and/or Prolapse Symptoms

(Include only if relevant to presenting concerns.)

• Pain location and quality: [anatomic areas] [quality descriptors]
• Pain behavior: [onset/duration] [aggravating/easing factors] [cycle-related / positional / sexual function related]
• Prolapse symptoms: [bulge/pressure sensation] [worsened by] [relieved by] [pessary use if applicable]

Prior Pelvic Floor Muscle Training

(Required documentation when biofeedback will be billed.)

• Prior attempts: [PFMT/Kegels / pelvic PT / apps/devices / prior biofeedback / none]
• Duration and adherence: [duration in weeks/months] [adherence level]
• Response to prior training: [improved / stable / worsened / unclear]
• Barriers identified: [understanding / technique / pain / schedule / access / other / none]
• Medicare coverage requirement for urinary incontinence biofeedback: [Completed ≥4 weeks of pelvic muscle exercises without clinically significant improvement: yes / no / unclear—plan to clarify]

Pertinent Medical, Surgical, and Obstetric History

• Pelvic/abdominal/urologic surgeries: [list with dates / none]
• Obstetric history: [GTPAL] [delivery types and years] [perineal trauma/episiotomy] [instrumentation] (Omit if not applicable.)
• Neurologic conditions: [MS / stroke / spinal cord injury / peripheral neuropathy / none]
• Endocrine/metabolic: [diabetes / other / none]
• Relevant gynecologic/urologic factors: [menopause status / hormone therapy / pessary / prostate status / prolapse grade if known]
• Medications affecting bladder/bowel: [diuretics / anticholinergics / alpha-blockers / opioids / laxatives / other / none]

Baseline Measures

• Diary status: [bladder / bowel / both] diary [reviewed today / not yet available]. [Dates covered and completeness if reviewed]. (If not available, document diary assigned: type, duration in days, instructions, and return date.)
• Standardized outcome measures: [Instrument name] [baseline score] [date] (Omit section if not administered.)

Objective Examination

General/Regional Screen

(Include findings relevant to pelvic floor function.)

• Posture and alignment: [observations]
• Breathing pattern: [diaphragmatic / apical / paradoxical] [coordination with pelvic floor]
• Abdominal wall: [bracing pattern observations] [diastasis assessment if relevant]

External Pelvic Floor Observation

• Perineal tissue/skin: [intact / atrophy / scar / edema / erythema / other]
• Voluntary contraction: [present / absent] [quality: appropriate lift vs bearing down/substitution]
• Voluntary relaxation: [complete / partial / delayed / absent]
• Bearing down response: [appropriate perineal excursion / paradoxical contraction]
• Coordination with breathing: [synchronous / asynchronous / breath holding]

Internal Pelvic Floor Examination

(Include if performed. If not performed, document reason and note findings are based on external assessment and biofeedback measures.)

• Route: [vaginal / rectal / both]
• Chaperone present: [yes—name/role / no]
• Patient tolerance: [well tolerated / mild discomfort / moderate discomfort / exam discontinued]
• Resting tone: [low / normal / elevated / asymmetrical]
• Tenderness/myofascial findings: [none / location(s) and severity]
• Strength: [grade] using [Laycock Modified Oxford / Brink / other scale]
• Endurance: [seconds held]
• Repetitions before fatigue: [#]
• Relaxation after contraction: [returns to baseline promptly / delayed / incomplete]
• Defecatory coordination: [appropriate relaxation with bearing down / dyssynergia pattern] (Include if relevant to presenting complaint.)

Biofeedback Baseline Findings

(Include if biofeedback was used today or will be initiated.)

• Modality: [surface EMG / manometry]
• Sensor type and placement: [intravaginal / intra-anal / perineal surface / external anal]
• Patient position: [supine / sidelying / sitting / standing]
• Resting activity level: [value with units] [stable / variable]
• Contraction peak amplitude: [value with units]
• Return to baseline after contraction: [prompt / delayed / incomplete]
• Endurance hold: [seconds] [quality of hold]
• Coordination tasks: [quick flicks / down-training / urge suppression / simulated defecation] [performance observations]
• Interpretation: [Brief summary linking biofeedback findings to functional complaints—e.g., elevated resting tone with difficulty down-training consistent with overactivity pattern, or reduced amplitude with poor endurance consistent with weakness]

Assessment

(Provide problem-oriented assessment. For each problem, summarize subjective complaint, objective impairment, functional impact, and clinical impression. Explain why skilled biofeedback therapy is indicated—what cannot be self-corrected without clinician-guided visual/auditory feedback. Include rehabilitation potential. Document red flags and actions taken. Do not assert diagnoses requiring medical testing; document concern and recommend workup.)

Problem 1: [Problem label]

• Subjective complaint: [summary]
• Objective impairment: [summary]
• Functional impact: [summary]
• Clinical impression: [weakness / overactivity / coordination deficit / mixed pattern]
• Rationale for skilled biofeedback therapy: [justification for why patient cannot self-correct without clinician-guided feedback]
• Rehabilitation potential: [good / fair / guarded] [factors affecting prognosis]

Problem 2: [Problem label]

(Include additional problems as applicable, using same format as Problem 1.)

Red flags and actions: [None identified / Concern noted for [issue]—[referral initiated / communication sent / recommended workup]]

Plan of Care

• Frequency and duration: [# sessions/week] for [# weeks]. Reassessment at [interval].
• Primary biofeedback training goal: [up-training for strength/endurance / down-training for elevated tone / coordination training for dyssynergia / urge suppression training]
• Training progression: [gravity-eliminated → antigravity → functional positions → integration into ADLs]. Criteria for progression: [measurable criteria].
• Biofeedback initiation: [initiated today / deferred to session #__ due to (reason)]
• Adjunct interventions: [manual therapy / stretching / strengthening / breathing retraining / toileting mechanics / bladder retraining / constipation management / urge suppression strategies] (Include as indicated.)
• Patient education provided: [Topics covered] [Patient understanding: verbalized / demonstrated / needs reinforcement] [Materials provided]
• Home program: [Specific exercises or relaxation drills with dosing parameters] [Diary completion instructions] [Behavioral homework] [When to contact clinic]
• Care coordination: [Communication to referring provider: sent / planned] [Referrals recommended with rationale] (Omit if none.)
• Follow-up: [Next appointment date/timing]

Signature

[Clinician name, credentials] [Date]