Patient Referral Form Dr Poongkodi Nagappan (PHKL) Referral Name(Required) First Last Contact Number (for appointment setting)(Required)For non-Malaysian numbers, kindly enter with your country code (e.g. +65xxxxx) Category(Required) Pelvic Floor Dysfunctions Vaginismus / Sexual Pain Chronic Gynae Pain Pregnancy Related Menopause Related Pregnancy Related(Required)Pregnancy Related. Tick all that applies Vaginal Laxity Perineal Tear Diastasis Recti Post-surgery rehab Post LSCS rehab General postnatal rehab Postural Dysfunction Pubic Symphisis Diastasis Menopause Related(Required)Menopause related. Tick all that applies Enuresis / Nocturia Mobility issues or challenges Sarcopenia Symptom Management Exercise Programme Pelvic Floor Dysfunctions(Required)Pelvic Floor Dysfunctions. Tick all that applies Urinary Incontinence Overactive Bladder Pelvic Organ Prolapse Pre/Post Hysterectomy Other Pelvic Surgery Rehab Chronic Pelvic Pain Syndrome Pelvic Instability Back Pain Chronic Gynae Pain(Required)Chronic Gynaecological Pain. Tick all that applies Dysmenorrhea Endometriosis Other / Overall pain Remarks / NotesE.g. non-listed conditions, other important informationWould you like to receive an acknowledgement copy of this form? Yes No Email(Required) NameThis field is for validation purposes and should be left unchanged. Δ
