Clinic template
A Cliniko treatment note template for a pelvic health physiotherapy assessment
This template covers continence and prolapse symptoms, validated questionnaire scores, and internal examination findings, with its own consent field placed before those findings so the record shows consent was sought and given, or that the patient declined, before any internal assessment happened. It is built as a Cliniko treatment note template, with the private information setting turned on given the record's sensitivity.
Last checked 25 Sep 2026 against the sources listed at the end of this page.
Free template ยท Cliniko
Treatment note: initial assessment: pelvic health physiotherapy
The template: 20 fields
| Section | Field | Type | Notes |
|---|---|---|---|
| Presenting problem | Reason for referral, in the patient's words | Paragraph | Cliniko type: Paragraph text. |
| Presenting problem | Referral source | Radio | Cliniko type: Multiple choice. Options: Self / GP / Gynaecologist / Continence nurse / Post natal service / Other. |
| Presenting problem | Obstetric and surgical history | Paragraph | Births, mode of delivery, pelvic surgery, as relevant. |
| Continence symptoms | Urinary symptoms | Checkboxes | Options: Stress leakage / Urge leakage / Frequency / Nocturia / Incomplete emptying / None. |
| Continence symptoms | Bowel symptoms | Checkboxes | Options: Incontinence / Constipation / Straining / Incomplete emptying / None. |
| Continence symptoms | Bladder and bowel diary reviewed | Radio | Options: Yes, attached to file / Given to complete before next visit / Not indicated. |
| Prolapse symptoms | Prolapse symptoms reported | Checkboxes | Options: Vaginal heaviness or dragging / Visible or palpable bulge / Symptoms worse by end of day / None reported. |
| Prolapse symptoms | Symptom impact on activity | Paragraph | What the patient has stopped or modified because of symptoms. |
| Questionnaire scores | Questionnaire used | Checkboxes | Options: ICIQ-UI Short Form / ICIQ-Vaginal Symptoms / Pelvic Floor Distress Inventory / Other. |
| Questionnaire scores | Score at this visit | Text | Cliniko has no number type, so use Single line text. Record the same questionnaire at review for a comparable score. |
| Internal examination consent | Internal examination discussed | Radio | Options: Discussed, patient consents / Discussed, patient declines / Not indicated this visit. This field comes before any internal findings are recorded. |
| Internal examination consent | What was explained | Checkboxes | Options: Purpose of the examination / What it involves / Risks and discomfort / Alternatives to internal examination / Right to stop at any point. |
| Internal examination consent | Consent notes | Paragraph | Anything specific to this patient's consent, including a chaperone request or a decision to stop partway through. |
| Findings | External observation | Paragraph | Completed regardless of internal examination consent. |
| Findings | Pelvic floor muscle assessment | Paragraph | Tone, strength (for example Modified Oxford Scale), coordination and any prolapse noted on examination. Leave blank if consent was declined. |
| Findings | Prolapse staging if assessed | Text | Record using the staging system your clinic uses, for example the International Continence Society's POP-Q system, stages 0 to IV. |
| Assessment | Clinical impression | Paragraph | |
| Assessment | Patient goals | Paragraph | In the patient's words. |
| Plan | Treatment plan | Paragraph | Pelvic floor exercise program, bladder or bowel retraining, referral, as relevant. |
| Plan | Review date and re-scoring plan | Text | When the questionnaire score above will be repeated. |
Build it in Cliniko
- Go to Settings > Treatment note templates as an Administrator, click Add template and name it Pelvic health initial assessment.
- Tick the option to restrict the template to be viewable by Practitioners and Administrators only, given the sensitivity of continence, prolapse and internal examination content.
- Add each section above with Add section, keeping Internal examination consent as its own section placed before Findings, so the template's own order enforces consent being recorded before any internal finding is entered.
- Set every question to one of Cliniko's six question types: Paragraph text, Single line text, Multiple choice, Checkboxes, Body chart or Date, and type out the Checkboxes and Multiple choice options exactly as listed.
- Leave the consent Radio question with no default answer, so a note cannot be saved showing consent as given unless a practitioner actively selects it.
- Assign the template to your pelvic health initial consultation appointment type.
- Test it on a sample patient, completing the consent section as declined once and as given once, and confirm the findings section behaves as expected either way before real patients are seen.
AHPRA: The shared Code of conduct that the Physiotherapy Board of Australia applies asks practitioners to obtain informed consent before any examination or treatment, with particular care around examinations that are more intimate or sensitive. Placing consent as its own field ahead of findings is how this template makes that sequence visible in the record itself, not just in what happened in the room.
Consent is a field, not an assumption
Most treatment note templates in this cluster record consent once, near the end, as a general checkbox. This one puts a dedicated consent section for the internal examination before the findings section that depends on it, because a pelvic health assessment is one of the few contexts in general physiotherapy practice where an examination itself, not just a technique like dry needling, needs its own explicit discussion of purpose, what is involved, and the right to decline or stop. Structuring the template this way means a practitioner physically cannot reach the internal findings fields without first passing through the consent field, which is a small design choice that makes the record match what should have happened in the room.
Why continence and prolapse get separate symptom sections
Continence and prolapse symptoms are grouped separately rather than combined into one general symptoms field because they point to different underlying problems and different questionnaires. Urinary and bowel symptoms are screened with checkboxes that mirror the categories used in standard continence questionnaires, while prolapse symptoms are screened for the specific sensations, heaviness, dragging, a palpable bulge, that patients often do not volunteer unless asked directly. Keeping the two apart also makes it easier to see at a glance which problem is driving today's visit when a patient presents with both.
Questionnaire scores repeat the same instrument on purpose
The questionnaire field is deliberately generic, naming a small set of validated tools such as the ICIQ short form and vaginal symptoms questionnaire, rather than building the full instrument into Cliniko. Run the actual questionnaire on paper or a linked patient form, then record the score here so the same instrument is repeated at review and the change over time is comparable, which matters for a GP or gynaecologist reading a progress letter later.
Sources
- Cliniko treatment note templates can be restricted so they are viewable only by Practitioners and Administrators, an option set when the template is created under Settings > Treatment note templates. Cliniko Help, checked 25 Sep 2026.
- The International Consultation on Incontinence Questionnaire family, including the ICIQ-Vaginal Symptoms module, is used alongside objective pelvic organ prolapse staging to evaluate symptoms and quality of life impact, with the objective staging system for pelvic organ prolapse (POP-Q) originally proposed by the International Continence Society. PubMed Central (peer reviewed literature review), checked 25 Sep 2026.
- Before a pelvic floor internal examination, a physiotherapist must discuss the purpose of the examination and what it involves, including risks, benefits and alternatives, in order to obtain informed consent, and the patient does not have to proceed if they do not wish to. Active Women's Health (patient information, reflecting standard pelvic health physiotherapy consent practice), checked 25 Sep 2026.
- The Physiotherapy Board of Australia applies the shared Code of conduct for registered health practitioners, which requires practitioners to obtain informed consent before assessment or treatment and to keep records that demonstrate this. Physiotherapy Board of Australia, checked 25 Sep 2026.