Female Pelvic Health QuestionnairePlease enable JavaScript in your browser to complete this form.Today's Date (MM/DD/YYYY): *Name *FirstLastAre you able to wait 2 hours between voids during the day? *YesNo SometimesAre you often waiting longer than 4 hours between voids? *YesNoSometimesAre you getting up at night (waking from sleep) to void? *Yes NoSometimesWhen urinating, does the amount that you void, usually match the amount of urgency? *YesNo SometimesHow often do you leak urine? *neverabout once a week or less oftentwo or three times a weekabout once a day several times a day all the time How much urine do you think usually leaks per episode? *none a small amount a moderate amount a large amount When does urine leak? (Check as many as appropriate.) *never - urine does not leak leaks before you can get to the toiletleaks when you cough or sneeze leaks when you are asleep leaks when you are physically active/exercisingleaks when you have finished urinating and are dressedleaks for no obvious reason leaks all the time How many pads/protective guards are you usually wearing in a 24H period? *Do you experience any difficulty emptying your bladdder? *YesNoSometimesIn general, what types/amounts of fluids are you drinking throughout the day? *Are you experiencing any fullness or heaviness (prolapse symptoms) in the pelvic area? *YesNoHow frequently do you have a bowel movement (Please specify #/day or #/week)? *Is this frequency your norm? *YesNoWhat is the consistency of your bowel? Please check all that apply. *liquid/diarrheasoftnormalfirmhardpebblesAre you experiencing any fecal/rectal incontinence/leakage? *YesNoAre you having to strain or push with bowel movements? *YesNoSometimesAny issues with bleeding or hemorrhoids with bowel movements in the past or present? *YesNoAre you currently pregnant? *YesNoIf yes, when is your due date (MM/DD/YYYY): Number of pregnancies: Number of vaginal deliveries: Number of c-sections: Do you have a history of physical and/or sexual abuse? *YesNoDo you have a history of or currently experience painful periods? *YesNoDo you have a history of urinary tract infections? *YesNoDo you have a history of or currently experience pelvic and/or abdominal pain? *YesNoDo you experience pain/discomfort in any of the following areas? *NoneArea between rectum and vagina (perineum)LabiaClitoris Below your waist in your pubic areaBelow your waist in your rectal areaDo you experience pain/discomfort with the following activities? *NoneUrinationDuring or after sexual climaxSubmit
