Contact Elnes Clinic | Toronto, ON

ELNES Clinic

Confidential client record

EMSELLA
Health Questionnaire & Informed Consent

Client information

Full name:

Date of birth:

Phone:

Email:

Date completed:

Preferred name:

Please answer every health question. Select one answer unless asked to select all that apply.
For symptoms, choose the option that best reflects your usual recent experience.
Use “Not applicable” or “Unsure” as needed. Add details where requested.
Sensitive concerns may be discussed privately.

Pelvic health questionnaire

What are your main pelvic health concerns and goals for treatment?

Main concerns (select all that apply):
Urine leakageUrgencyNight-time urinationOther

Other concerns / treatment goals:

If applicable, describe your pregnancy and delivery history, including the number of
pregnancies, vaginal deliveries or C-sections, dates and any complications.

Not applicableNo previous pregnanciesPrevious pregnancies

Pregnancies:

Vaginal deliveries:

C-sections:

Last delivery date:

Complications / relevant details:

Do you experience urine leakage when you laugh, cough or sneeze?
NeverSometimesOftenAlwaysNot applicable

Do you experience urine leakage when you run, jump or exercise?
NeverSometimesOftenAlwaysNot applicable

If applicable, do you experience vaginal pressure, heaviness or a bulge?
Have you been diagnosed with pelvic organ prolapse? If yes, state the degree, if known.

Vaginal pressure/heaviness/bulge:
YesNoUnsureNot applicable

Diagnosed prolapse:
YesNoUnsureNot applicable

If yes, degree / details:

Do you experience a sudden, urgent need to urinate? If yes, how often?
NeverSometimesOftenAlways

Do you urinate before you feel the need, to avoid having to stop while driving
or during other activities?

NeverSometimesOftenAlwaysNot applicable

Do you limit your fluid intake to avoid using the bathroom?
NeverSometimesOftenAlways

Describe your bowel habits, including regularity, constipation, diarrhoea or bowel leakage.

Select all that apply:

RegularConstipationDiarrhoeaBowel leakageOtherUnsure

Details:

Do you have any sexual health concerns you would like to discuss, such as pain during sex,
vaginal dryness, difficulty reaching orgasm or erectile difficulties?
(Optional; you may discuss these privately with the provider.)

YesNoPrefer to discuss privately

Optional details:

How many times per night do you wake up to urinate?

01234 or moreUnsure

How long have you had your symptoms? Have they changed recently?

Less than 3 months3-6 months6-12 monthsMore than 1 yearNo current symptomsUnsure

Changed recently?

YesNoUnsure

Details:

Health and safety screening

Do you wear any removable metal items between your waist and knees, such as piercings,
a belt or metal clothing fasteners? Please specify.

YesNoUnsure

Items / location:

Do you have any metal or electronic implants anywhere in your body, such as a pacemaker,
defibrillator, neurostimulator, drug pump, joint replacement, surgical plates/screws or a
copper IUD? State the type and location. If you have any IUD, provide its brand/type if known.

YesNoUnsure

Type / location / IUD brand (if applicable):

Are you pregnant, or is there any possibility that you may be pregnant?
(Yes / No / Unsure / Not applicable)

YesNoUnsureNot applicable

If applicable, what was the first day of your last menstrual period, or your age at menopause?
Are you currently menstruating?

Last period start:

Age at menopause (if applicable):

Not applicable

Currently menstruating?

YesNoUnsureNot applicable

Do you have pulmonary insufficiency, a malignant tumour/cancer, a heart condition
or a bleeding disorder? Please identify each condition that applies.

YesNoUnsure

Condition(s) / details:

List all medications you take, including prescriptions, over-the-counter medicines,
supplements and herbal products. Include any blood-thinning medication.

Taking medications / supplementsNoneUnsure

List all, including any blood thinners:

Do you have any allergies to medications, foods or other substances?
Please describe your reactions.

YesNoUnsure

Allergies and reactions:

Have you had any recent surgeries? State the procedure, date and whether you are fully healed.
Include relevant pelvic, abdominal or prostate surgery.

YesNoUnsure

Procedure / date / healing status:

Do you use incontinence pads or briefs? If yes, how many per day?

YesNoUnsure

Number used per day:

Additional screening

For each item below, mark Yes, No or Unsure. A “Yes” or “Unsure” answer requires provider
review and may require deferral or further assessment. Not every item is an absolute contraindication.

Fever, current infection, urinary tract infection symptoms or feeling unwell

YesNoUnsure

Blood in urine, burning/pain when urinating or difficulty emptying the bladder

YesNoUnsure

Unexplained vaginal bleeding, new/severe pelvic pain or pain with pelvic muscle contractions

YesNoUnsure

Skin disease, irritation, wounds or reduced sensation in the treatment area

YesNoUnsure

Neurological condition or nerve injury affecting bladder function or pelvic sensation

YesNoUnsure

Previous pelvic floor treatments, physiotherapy, EMSELLA, pelvic implants/mesh or relevant procedures

YesNoUnsure

Any other medical condition or concern not disclosed above

YesNoUnsure

A healthcare professional has advised against this treatment or requested further assessment

YesNoUnsure

Details of any Yes/Unsure answer:

Previous treatments and response:

Informed consent — initial each section

Client name:

Date:

Treatment, preparation and purpose

I understand that BTL EMSELLA uses non-invasive electromagnetic stimulation for weak
pelvic muscles and urinary incontinence. I remain clothed and may feel tingling and
strong muscle contractions. I will remove metal objects and keep electronic devices
away as required by the manufacturer instructions and my treatment provider.
Treatment does not replace medical assessment of my symptoms.

Client initials:

Individual treatment plan and monitoring

My provider will explain my suitability, treatment plan and follow-up. BTL describes
a typical course of six sessions, about 30 minutes each, twice weekly; my actual schedule
will follow the applicable instructions and clinical assessment. Treatment requires
supervision by a licensed practitioner and continuous monitoring. Additional sessions
may be recommended. Completing a series does not guarantee improvement.

Client initials:

Health disclosure and contraindications

I have disclosed my conditions, medications, allergies, surgeries, implants and symptoms
accurately. BTL states that treatment must not be applied to patients with electronic or
metal implants. Its published materials also identify pregnancy, malignant tumour, fever,
pulmonary insufficiency and heart disorders as reasons not to treat. My provider must check
the full contraindications and precautions in the applicable device instructions before
treatment; signing this form or obtaining generic medical clearance does not override them.
I will report health changes before each session.

Client initials:

Pregnancy and menstrual status

I understand that EMSELLA must not be used during pregnancy. I will report pregnancy or
any possibility of pregnancy before treatment. BTL’s sample consent also excludes treatment
during menstruation; ELNES Clinic will defer treatment during menstruation unless current
written BTL instructions applicable to its device confirm otherwise. I will report unusual bleeding.

Client initials:

Risks and stopping treatment

I understand that possible side effects include muscle soreness or pain, temporary muscle
spasm, joint or tendon discomfort and local skin redness. Other complications or unexpected
effects may occur. I will immediately report uncomfortable pain or unusual symptoms; the
treatment should be stopped and assessed by my provider. I understand that I can ask to stop
at any time.

Client initials:

Informed consent — continued

Results and limitations

I understand that results differ between individuals, cannot be predicted or guaranteed,
may not meet my expectations and may include no noticeable improvement. Benefits may not
be permanent. I understand that this consent does not promise relief of every pelvic or
sexual health concern.

Client initials:

Alternatives and questions

My provider has discussed reasonable alternatives relevant to my condition, which may include
pelvic floor physiotherapy, bladder training, medical treatment, specialist assessment or
choosing no treatment. I have had the opportunity to ask questions, and my questions have
been answered to my satisfaction. I understand the proposed treatment and its material risks
and limitations.

Client initials:

Clinical records

I understand that my questionnaire, consent and treatment information will be retained as part
of my confidential client record and used for assessment, treatment and follow-up in accordance
with the clinic privacy notice. This consent does not authorize promotional use, publication of
my identity or photographs, or research participation; any such use requires separate consent.

Client initials:

Voluntary consent

I voluntarily request and consent to BTL EMSELLA treatment at ELNES Clinic by the appropriately
qualified treatment provider. I may decline treatment or withdraw my consent for future treatment
at any time. My initials acknowledge each section; they do not waive my legal rights.

Client initials:

Accuracy and confirmation

I confirm that the information I have provided is accurate and current to the best of my knowledge,
that I have read and understood this form, and that I will inform ELNES Clinic of changes before
treatment. I understand that signing this form alone does not establish my medical suitability.

Client initials:

Client signature

By typing your full name below, you confirm that you have read, understood, and agree to this consent form,
and you agree to use your typed name as your electronic signature.

Full Name (Electronic Signature) *

Or draw your signature below *