Please answer each question by checking the best response. While answering these questions, please consider your symptoms over the last 3 months. We realise that you may not be having problems in some of these areas but please fill out both sides of this form as completely as possible.
Do you experience, and if so, how much are you bothered by…..
Usually experience frequent urination?
Not at allSomewhatModeratelyQuite a bit
Usually experience urine leakage associated with a feeling of urgency, this is, a strong sensation of needing to go to the bathroom?
Usually experience urine leakage related to coughing, sneezing, or laughing?
Usually experience small amounts of urine leakage (that is, drops)?
Usually experience difficulty emptying your bladder?
Usually experience pain or discomfort in the lower abdomen or genital region?
Feel you need to strain too hard to have a bowel movement?
Feel you have not completely emptied your bowel at the end of a bowel movement?
Usually lose stool beyond your control if your stool is well formed?
Usually lose stool beyond your control if your stool is loose?
Usually lose gas from the rectum beyond your control?
Do you usually have pain when you pass your stool?
Experience a strong sense of urgency and have to rush to the bathroom to have a bowel movement?
Does part of your bowel ever pass through the rectum and bulge outside during or after a bowel movement?
Usually experience pressure in the lower abdomen?
Usually experience heaviness or dullness in the pelvic area?
Usually have a bulge or something falling out that you can see or feel in your vaginal area?
Ever have to push on the vagina or around the rectum to have or complete a bowel movement?
Usually experience a feeling of incomplete bladder emptying?
Ever have to push up on the bulge in the vaginal area with your fingers to start or complete urination?
Please answer the below questions in relation to the relevant heading.
Ability to do household chores (cooking, housecleaning, laundry)?
Bladder or Urine
Bowel or Rectum
Vagina or Pelvis
Ability to do physical activities such as walking, swimming, or other exercise?
Entertainment activities such as going to a movie or concert?
Ability to travel by car or bus for a distance greater that 30 minutes away from home?
Participating in social activities outside your home
Emotional health (nervousness, depression, etc)?
The Data Protection Officer with responsibility for monitoring this privacy notice is Katie Ballard.
We may collect the following information:
• Contact information including email address
• Demographic information, such as postcode, preferences and interests
• Personal information including detailed medical information for the purposes of providing treatment.
• Other information relevant to client enquiries
Collecting this data helps us to ensure that we can provide a safe and beneficial service to our clients.
Specifically, we may use data:
• To ensure that we have the information required to provide safe and appropriate physiotherapy or Pilates service.
• To handover to members of the team who may be involved in the care pathway.
• To ensure that we meet the statutory requirements for the HCPC governing physiotherapists.
• To contact you via email, telephone or email regarding your inquiry.
• To send you details of offers, updates on services and free wellness and self-help guidance.
– We will never lease, distribute or sell your personal information to third parties unless we have your permission or the law requires us to do so.
– Information is not stored for the purpose of sending automated emails regarding our services.
Through agreeing to this privacy notice you are consenting to KTB Rehabilitation processing your personal data for the purposes outlined. You can withdraw consent at any time or if you would like to discuss anything in this privacy notice, please contact Katie Ballard at KTB Rehabilitation Westgate House Spital Street Dartford DA1 2EH or by email Katie@www.pilatesandtherapy.co.uk
If you have a concern about the way we are collecting or using your personal data, you should raise your concern with us in the first instance or directly to the Information Commissioner’s Office at https://ico.org.uk/concerns/
Access to your information
Your rights as a data subject
At any point whilst we are in possession of, or processing your personal data, all data subjects have the following rights:
• Right of access – you have the right to request a copy of the information that we hold about you.
• Right of rectification – you have a right to correct data that we hold about you that is inaccurate or incomplete.
• Right to be forgotten – in certain circumstances you can ask for the data we hold about you to be erased from our records.
• Right to restriction of processing – where certain conditions apply you have a right to restrict the processing.
• Right of portability – you have the right to have the data we hold about you transferred to another organisation.
• Right to object – you have the right to object to certain types of processing such as direct marketing.
• Right to object to automated processing, including profiling – you also have the right not to be subject to the legal effects of automated processing or profiling.
To access what personal data is held about you, identification will be required. One piece of photographic ID and one item of supporting documentation such as a utility bill or bank letter will be required. Requests should be made to Katie Ballard.
To prevent unauthorised disclosure or access to your information we have implemented strong physical and electronic security safeguards.
Our website is scanned on a regular basis for security holes and known vulnerabilities in order to make your visit to our site as safe as possible.
Your personal information is contained behind secured networks and is only accessible by a limited number of persons who have special access rights to such systems, and are required to keep the information confidential. All our data processors have been vetted to comply with GDPR safety regulations.
Only staff engaged in providing your treatment will have access to your patient records, although our administration team will have access to your contact details so that they can make appointments and manage your account.
KTB Rehabilitation will not disclose your Personal Information unless compelled to, in order to meet legal obligations, regulations or valid governmental requests.
Our website may contain links to other websites. Please note that we have no control of websites outside the KTB Kids domain. If you provide information to a website to which we link, we are not responsible for its protection and privacy.
Always be wary when submitting data to websites. Read the site’s privacy policies fully.
KTB Rehabilitation will process personal data during the duration of any treatment and will continue to store only the personal data needed for eight years after the contract has expired to meet any legal obligations. After eight years, all personal data may be deleted, unless basic information needs to be retained by us to meet our future obligations to you, such as erasure details. Records concerning minors who have received treatment will be retained until the child has reached the age of 25.
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