Haastattelu- ja tutkimuslomake                                                                     

                                                                                                                                   Pvm              

Kuntoutujan nimi                                                                                                        Syntymäaika                      

 

Puhelinnumero                                                                                   

Pituus            cm                 Paino           kg                    Painoindeksi (BMI)                    

 

Perussairaudet                                                                                                                                                                                                                                                                                                                                  

Lääkehoito                                                                                                                                                           

                                                                                                                                                                             

Virtsankarkailun haittaavuus päivittäisessä elämässä / Tilanteet, missä virtsankarkailua esiintyy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           

Subjektiivinen haitta-aste                  %                          Erottelupisteet                                          

 

Diagnoosi

 

ponnistusinkontinenssi

 

pakkoinkontinenssi

 

sekamuotoinkontinenssi

 

ylivuotoinkontinenssi

 

 

 

neurogeenineninkontinenssi

 

ulosteinkontinessi

 

ummetus

 

kipu

 

 

Oireiden kesto                                                                                                                                                      

Ongelman aikaisemmat hoidot / tutkimukset / fysioterapia                                                                                                                                                                                                                                                                                                                                                                                                                                              

 

Ammatti                                                                                                                                                                

Liikunta harrastukset                                                                                                                                                                                                                                                                                                                          

Tupakointi

 

Ei

 

Kyllä

 

 

Kuinka monta savuketta päivässä?                                                                   

 

Onko sinulla ollut?

Ei

Kyllä

virtsatieinfektioita

 

 

cystillis

 

 

yökastelua/virtsankarkailua lapsuudessa

 

 

tarvetta suojien käyttöönp>

 

 

kuulia käytössäsi lantionpohjan harjoitteluun

 

 

virtsankarkailua tietyssä kuukautiskierron vaiheessa

 

 

                                                                                                                                                                                                                                                                    

Kuukautiskierron pituus / Menopaussi vuonna                                                                                                     

 

Hormonikorvaushoito                                                                                                                                                                                                                                                                                                                         


                                           

Synnytykset

 

Lapsen syntymävuosi

Lapsen syntymäpaino (g)

 

 

 

 

 

 

 

 

 

 

Synnytysvaikeudet

ei mitään

 

käynnistetty

 

pihti / imukuppi

 

sectio

 

 

pitkä synnytys

 

episiotomiat

 

välilihanrepeämä

 

muuta

 


Gynekologiset leikkaukset                                                                                                                                                                                                                                                                                                                  

 

Sukupuolielämä

Ei

Kyllä

onko sukupuolielämää

 

 

pahenevatko oireet yhdynnässä

 

 

karkaako virtsa yhdynnän aikana

 tai sen jälkeen

 

 

onko yhdyntäkipuja

 

 

käytätkö lantionpohjanlihaksia yhdynnän aikana

 

 

 

                                                                                                                                                                            

                                                                                                                                                                            

                  


Selkäkivut                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          


Lannerangan ryhti                                   

normaali

 

hyperlordoosi

 

skolioosi

 

lautaselkä

 

Lannerangan liikkuvuus

 

symmetrinen

 

epäsymmetrinen

 

 

Lantionpohjan palpointi

(limakalvojen kunto, kipupisteet, yskäisy)                                                

                                                                                                            

                                                                                                                     O                              V

                                                                                                            

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