Virtual Pelvic Floor Therapy Intake Form

Virtual pelvic floor therapy has become an increasingly accessible and effective treatment option for individuals experiencing pelvic health concerns. This Virtual Pelvic Floor Therapy Intake Form provides healthcare practitioners with a comprehensive, HIPAA-compliant tool to gather essential patient information before remote consultations.

Designed specifically for pelvic floor physiotherapists and telehealth clinics, this template streamlines the intake process by capturing detailed symptom information, treatment history, and baseline functional assessments—all before the first virtual appointment. By collecting this information upfront, practitioners can maximize consultation time and develop more personalized treatment plans from the very first session.

The form includes a validated symptom severity questionnaire that helps quantify the impact of pelvic floor dysfunction on daily activities, work, and quality of life. Patients can upload bladder diaries, previous diagnostic reports, and relevant medical documentation, ensuring therapists have a complete clinical picture before the appointment begins.

Paperform makes this telehealth workflow seamless. With conditional logic, the form adapts based on patient responses—showing relevant follow-up questions only when needed. The file upload functionality allows secure submission of bladder diaries and medical records, while embedded consent forms ensure patients understand their home exercise program responsibilities before treatment begins.

For practices looking to further streamline operations, Stepper can automate post-submission workflows: automatically scheduling follow-up appointments based on symptom severity, sending intake information to your practice management system, triggering welcome emails with pre-appointment instructions, and creating patient records in your EHR—all without manual data entry.

Whether you're a solo practitioner expanding into telehealth or a multi-provider pelvic health clinic, this form template helps you deliver professional, patient-centered care from the first digital interaction.