Women's Health/Pelvic-Floor Disorder

Swedish Outpatient Rehabilitation Services

Women’s Health/Pelvic-Floor Disorder Referral Form

Patient name______DOB______

M.D. name (print)______

Patient phone number______

DIAGNOSIS

___ OB-GYN Musculoskeletal ___ Pelvic-Floor Laxity ___ Coccyodynia ___ 1º or 2º Cystocele ___ Diastasis Recti ___ 1º or 2º Rectocele ___ Groin/Pubic Pain ___ Uterine Prolapse ___ Ligament Laxity ___ Other______Low Back Pain ___ Incontinence ___ Osteoporosis ___ Fecal Incontinence ___ Rib Pain ___ Mixed Urinary Incontinence ___ Sciatica ___ Stress Urinary Incontinence ___ Thoracic Outlet Syndrome ___ Urge Urinary Incontinence ___ Other______Post-Surgical Conditions ___ Pelvic-Floor Pain/Tension (Ballard and First Hill only) ___ Bladder Repair ___ Abdominal Pain ___ Cesarean Section ___ Chronic Constipation ___ Episiotomy ___ Dyspareunia ___ Hysterectomy ___ Levator Ani Syndrome ___ Laparoscopy ___ Piriformis Syndrome ___ Mastectomy ___ Vaginismus ___ Other______Vulvar Pain ___ Other______

TREATMENT

___ Evaluate and treat ___ Prenatal/postpartum exercise class ___ Contraindications/Other instructions______Other______

Physician’s Signature______Date______

(maps on reverse side)

Ballard Cherry Hill First Hill West Seattle Rehab 5300 Tallman Ave. N.W., 1-S 500 17th Ave. 1101 Madison, Suite 200 3400 California Ave. S.W., Seattle, WA 98107 James Tower, Suite 100 Seattle, WA 98104 Suite 100 T 206-781-6346 Seattle, WA 98122 T 206-386-2035 Seattle, WA 981116 F 206-781-6191 T 206-320-2404 F 206-386-2999 T 206-320-5510 F 206-320-4747 F 206-320-5522

For a free physician referral: 1-800-SWEDISH (1-800-793-3474) www.swedish.org Locations

N.W. MARKET ST. EAST CHERRY STREET T A L L M A N A V NE W . . Courtyard Swedish

B A R N E SA V NE W. . Medical Ballard Medical Medical Plaza Center East 1 8 T H A V E . 1 6 T H A V E . West Clinic Building Ballard Campus Tower Professional Tower 1st Floor Tunnel Building Tallman Medical OUTPATIENT Center REHAB SERVICES

3rd Floor Skybridge Center Building James Tower Parking Garage Main Main Entrance R U S S E L LA V NE W. . Entrance Parking Patient Nursing Garage Drop-Off Tower 17th AVE. N.W. Short term parking REHAB SERVICES 1st FLOOR Jefferson Tower Annex/ Central N.W. CENTRAL PL Plant Swedish

Annex I Medical EAST JEFFERSON STREET Center Cherry Hill Campus

Swedish Medical Center/Ballard Swedish Medical Center/Cherry Hill Outpatient Rehabilitation Services Outpatient Rehabilitation Services 5300 Tallman Ave. N.W., 1-S 500 17th Ave., James Tower, Suite 100 Seattle, WA 98107 Seattle, WA 98122 T 206-781-6346 T 206-320-2404

OUTPATIENT REHAB S.W. ADMIRAL WAY SERVICES MADISON ST. Madison 1401 Medical Madison Y A W L A R I M D A W. . S Tower Arnold Bldg. Minor & Marion Pavilion Nordstrom S.W. HANFORD ST. Parking Garage Medical Tower WEST SEATTLE M A R I O N S T . BOYLSTON AVE. REHAB North S . W . H I N D S SERVICES

S . W . H I N D S West Heath Bldg. Swedish East S.W. SPOKANE BROADWAY AVE. Physicians COLUMBIA ST. Seattle

West Seattle 35TH AVE. S.W. South Main University West Entrance

S.W. ANDOVER ST. W

South S

M I N O R A V E . A CALIFORNIA AVE. S.W. W B O R E N A V E . Swedish C H E R R Y S T . Y O Medical S.W. GENESEE ST. R E L Center T Minor & James First Hill Campus N Parking Garage U Orthopedic A F Institute 600 Broadway S.W. ALASKA ST.

J A M E S S T . Swedish Medical Center/First Hill West Seattle Rehabilitation Services Outpatient Rehabilitation Services 3400 California Ave. S.W. 1101 Madison, Suite 200 Seattle, WA 98116 Seattle, WA 98104 T 206-320-5510 T 206-386-2035