What this resource is
This printable worksheet helps a qualified clinician document an individualized pelvic-floor exercise plan and helps the patient understand what each variable means. It does not prescribe a programme by itself, and blank fields should remain blank until an appropriate assessment or professional instruction supplies the values.
Print this page from the browser when a paper copy is useful. Navigation, advertising spaces, and promotional calls to action are hidden in print, while the instructions, blank fields, related context, and sources remain.
Review the on-screen version again if the page shows a newer update date.
How to use the handout
Complete the worksheet together where possible. State the target problem, prerequisites, movement cue, training variables, functional practice, stop rules, and review date. If several goals are present, clarify whether they can share one programme or need separate phases. The patient should not increase a variable merely because the page has space for it.
Read every safety boundary before completing the fields. Keep a completed copy private because bladder, bowel, sexual-health, pregnancy, surgery, or symptom notes can be sensitive. This resource is educational and does not establish a clinician–patient relationship.
Define the target before the dose
Pelvic-floor training may target awareness, coordination, strength, endurance, power, relaxation, timing with pressure, or a task-specific response. the ICS Incontinence reference frames PFMT as repeated, structured training rather than an isolated squeeze. Write the intended change and population first so the variables below have a clear rationale.
Describe technique in observable terms
Record the position, verbal or visual cue, breathing strategy, permitted accessory activity, expected release, and signs of bearing down or substitution. If technique was checked, note how and by whom without implying that a timer or self-report is an objective muscle test. Consent and comfort govern any internal assessment; the worksheet does not require one.
Progress one variable deliberately
A progression might change effort, duration, repetitions, sets, position, speed, rest, task complexity, or frequency. Changing several at once makes tolerance and attribution harder to interpret. the exercise-programming textbook record supports explicit training principles, while NICE guidance reinforces individualized assessment and management boundaries.
Plan reassessment and regression
Write what counts as an acceptable response, when to repeat an assessment, and how to reduce or pause load if form or symptoms deteriorate. Include the clinician instruction that overrides the general app. A plan without a review rule can encourage indefinite repetition even when the target has changed, progress has plateaued, or a different condition needs attention.
Personal or clinician-supplied fields
Leave any item blank when it has not been assessed or agreed. Blank space means “not supplied”; it is not an invitation to invent a dose, diagnosis, treatment date, or clearance decision.
Assessment summary, target, prerequisites, and exclusions
Technique cue, position, breathing, and release criteria
Effort, timing, rest, repetitions, sets, frequency, and functional task
Progression, regression, stop rules, review date, and responsible clinician
Safety and review boundaries
Pause an exercise that causes pain or clearly worsens symptoms.
Seek a qualified pelvic-health physiotherapist or other appropriate clinician when technique is uncertain, symptoms are complex, emptying is difficult, a programme is not helping, or treatment and recovery affect exercise choice.
New or severe symptoms may require medical assessment rather than an exercise review.
The page cannot examine tissue healing, muscle activity, sensation, coordination, prolapse, retention, infection, neurological function, or the reason for leakage. A completed form records observations and instructions; it does not convert them into a diagnosis or prove that the exercise was performed correctly.
Review before reusing
Date the printed copy and replace it when professional instructions, symptoms, medicines, pregnancy stage, catheter status, treatment, or functional goals change. Do not keep progressing an old plan because it is convenient.
If the resource is shared by a clinician, that clinician remains responsible for checking that the written variables and safety route fit the individual.
Related guides
Continue with Why there is no single universal Kegel prescription, Why a program should progress one training variable at a time, and Clinician-shareable free Kegel timer.
Sources
- Bø K, Berghmans B, Mørkved S, Van Kampen M, eds. Evidence-Based Physical Therapy for the Pelvic Floor. 3rd ed. Elsevier; 2023. Chapter 5: Measurement of Pelvic Floor Muscle Function and Strength. Official or indexed source.
- Cardozo L, Rovner E, Wagg A, Wein A, Abrams P, eds. Incontinence. 7th ed. International Consultation on Incontinence and International Continence Society; 2023. Chapter 8, section 2: Pelvic Floor Muscle Training, p. 807. Official or indexed source.
- Frawley H, Shelly B, Morin M, et al. An International Continence Society (ICS) report on the terminology for pelvic floor muscle assessment. Neurourol Urodyn. 2021;40(5):1217-1260. doi:10.1002/nau.24658. Official or indexed source.
- National Institute for Health and Care Excellence. Pelvic floor dysfunction: prevention and non-surgical management. NG210. 2021. Official or indexed source.