Pelvic Symptom Questionaire
Full Name
*
First Name
Last Name
Birth Date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
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10
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13
14
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30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
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1931
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1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Trouble initiating urine stream
*
Yes
No
Urinary intermittent/slow stream
*
Yes
No
Trouble emptying bladder
*
Yes
No
Difficulty stopping the urine stream
*
Yes
No
Straining or pushing to empty bladder
*
Yes
No
Dribbling after urination
*
Yes
No
Blood in urine
*
Yes
No
Painful urination
*
Yes
No
Trouble feeling bladder urge/fullness
*
Yes
No
Trouble feeling bowel/urge/fullness
*
Yes
No
Current Laxative use
*
Yes
No
Constipation/straining
*
Yes
No
Trouble holding back gas/feces
*
Yes
No
Recurrent bladder infections
*
Yes
No
Frequency of Urination while awake
Please Select
1 Times a day
2 Times a day
2-5 Times a day
5-7 Times a day
more than 10 times a day
Frequency of Urination sleep hours
Please Select
1 Time
2 Times
2-5 Times
5-7 Times
more than 10 times
The usual amount of urine passed is
*
Please Select
Small
Medium
Large
When you have a normal urge to urinate, how long can you delay before you have to go to the toilet?
Please Select
1 minute
2 minutes
3-5 minutes
10 minutes
15 minutes
30 minutes
1 hour
2 hours
more than 2 hours
not at all
When you have an urge to have a bowel movement, how long can you delay before you have to go to the toilet?
Please Select
1 minute
2 minutes
3-5 minutes
10 minutes
15 minutes
30 minutes
1 hour
2 hours
more than 2 hours
not at all
Frequency of bowel movement
*
Daily
2 or more daily
Once a week
Every other day
Other
If constipation is present describe management techniques.
Average fluid intake (one glass 8oz or one cup) Glasses per day
How many glasses are caffeinated? per day
Rate a feeling of organ "falling out" / prolapse or pelvic heaviness/pressure
*
None Present
Several times per month (please specify below)
With standing ( please specify below)
With exertion or straining
Other
Explain
Ob/Gyn History
Childbirth number of vaginal deliveries
Childbirth number of C-section deliveries
Episiotomy #
Number of difficult childbirth
Menopause- When?
Prolapse or organ falling out
*
Yes
No
Vaginal Dryness
*
Yes
No
Painful periods
*
Yes
No
Painful vaginal penetration
*
Yes
No
Pelvic pain
*
Yes
No
Skip questions if no leakage/incontinence
Bladder leakage- number of episodes
No leakage
Only with physical exertion/cough
Several times a day (explain)
Several times a week (explain)
Several times a month (explain)
Explain
Bowel leakage- number of episodes
No leakage
Only with physical exertion/cough
Several times a day (explain)
Several times a week (explain)
Several times a month (explain)
Explain
On average , how much urine do you leak?
No leakage
Just a few drops
Wets underwear
Wets outerwear
Wets the floor
How much stool do you lose?
No leakage
Stool staining
Small amount in underwear
Complete emptying
What form of protection do you wear?
None
Minimal Protection ( Tissue paper/paper towel/pantishields)
Moderate protection ( absorbent product, maxipad)
Maximum protection ( Specialty product/diaper)
Other
On average, how many pad/protection changes are required in 24hrs? #of pads
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