Name * First Name Last Name Email * Do you leak urine with any activity or exercise? Yes No Do you go to the toilet more than once every 2-3 hours? Yes No Do you experience a strong urge to go to the bathroom and have difficulty holding on? Yes No Are you unable to stop the flow of urine? (Please note that we do NOT encourage this as an exercise but can be a helpful once-off test) Yes No Do you have difficulty starting the stream of urine? Yes No Are you unable to completely empty your bladder? Yes No Do you experience difficulty holding stool in? Yes No Do you have any trouble getting everything out? Yes No Do you experience constipation and require to strain to empty your bowels? Yes No Do you have ANY pain with sex? Keep in mind that 'pain' can range from mild discomfort to intense, sharp burning pain. Yes No Do you struggle to reach orgasm? Yes No Do you have any discomfort or pain around the vulva (or labia) with tight clothing or light touch to the area? Yes No Do you experience any pain with the use of tampons or during a pap smear? Yes No Do you have any pain with urinating or bowel movements? Yes No Do you have any pain in the vagina? Yes No Do you have any sharp stabbing pains into the rectum OR abdomen? Yes No Do you feel any heaviness or pressure in the vagina or rectum? Yes No Have you noticed a bulge into the vagina or the feeling of something 'falling out'? Yes No Do you have tailbone pain lasting more than one month? Yes No Do you have pain in your pubic bone, sacro-iliac joint (SIJ), lower back, hip or groin that doesn't respond to regular treatment? Yes No Do you experience a lot of abdominal cramping pain with periods? Yes No Thank you! We will go over your responses at your prenatal appointment. Pelvic Health Assessment Form
