Holistic Pelvic Care SOAP Note form(For internal use only) Client Name * First Name Last Name Therapist Name * Gabrielle Cierra Therapist to be determined Date of appointment * MM DD YYYY Age Gender Diagnosis Please describe the clients chief concerns: * Health History Current Symptoms (pain rating 0-10) Activities of daily life (functional rating from 0-10) External Palpation of perineal area (pain rating from 0-10) Internal Assessment: Cystocele Rectocele Uterine Prolapse None Vaginal pain (0-10) Rectal Pain (0-10) Baseline tone Quality of contraction C. MMT(0-5) Right, Posterior, Left, Anterior Decreased pelvic strength in _ quadrants One Two Three Four Treatment Included: Evaluation Vaginal/Rectal MFR Pelvic anatomy education Plan: Home Exercise Manual Therapy technique Proprioceptive training
