Pelvic Floor Survey

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Name *

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Last

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Do you have urine leakage when coughing, laughing, sneezing, or lifting something heavy? (Even a few drops of leakage are significant)

• Yes
• No

Do you have urine leakage associated with urgency?

• Yes
• No

Do you have difficulty or incomplete emptying of bladder?

• Yes
• No

Do you have difficulty or incomplete emptying of rectum?

• Yes
• No

Do you wake up more than twice/night to urinate?

• Yes
• No

Do you have a feeling of fullness in vaginal area?

• Yes
• No

Do you have a feeling of fullness in rectum?

• Yes
• No

Do you have straining or pain with bowel movements?

• Yes
• No

Chronic Constipation?

• Yes
• No

Do you have stool leakage of any kind?

• Yes
• No

Do you have urgency associated with bowel movements?

• Yes
• No

Do you have involuntary loss of gas?

• Yes
• No

Do you have loss of urine, stool, or gas with intercourse?

• Yes
• No

Are your bladder or bowel control issues causing you to feel nervous, frustrated, or depressed?

• Yes
• No

Has loss of bladder or bowel control affected your lifestyle?

• Yes
• No

Do you have decreased sexual desire?

• Yes
• No

Do you have pain with intercourse?

• Yes
• No

Do you have chronic pelvic pain?

• Yes
• No

Do you have vaginal dryness?

• Yes
• No

Submit

If you answer YES to one or more of these questions, you may be experiencing pelvic problems that are very treatable. A Pelvic Floor PT Specialist is available to talk to you privately about your options.