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Pelvic Floor Qestionnaire

  • How has your lifestyle/quality of life been altered/changed because of this problem?

  • Since the onset of your current symptoms have you had:

  • Health History

  • Mental Health

  • Surgical/Procedure History

  • Ob/Gyn History (Females Only)

  • Males Only

  • Pelvic Symptom Questionnaire

  • Bladder/Bowel Habits/Problems

  • Frequency of urination:

  • Rate a feeling of organ “falling out”/prolapse or pelvic heaviness/pressure:

  • Skip questions if no leakage/incontinence.