Pelvic Floor Questionnaire

This screening questionnaire is designed to help you assess your symptoms. These questions are not intended to diagnose pelvic floor disorders, but help you decide whether you should see a specialist.

Do you experience urinary leakage:

With laughing, coughing, sneezing?
YesNo

with exercise, running, jumping?
YesNo

Do you have accidental bowel leaks?
YesNo

Do you experience a sudden urge to go to the bathroom and find you can't get there on time?
YesNo

Do you wear liners or pads to protect your clothing from urine leakage?
YesNo

Do you urinate more than two times per night?
YesNo

Do you have bowel or urine accidents while asleep?
YesNo

Do you have a feeling of bulge, fullness or heaviness in the pelvic area, especially do any movement?
YesNo

Do you have pelvic pain or discomfort?
YesNo

Do you experience vaginal dryness?
YesNo

Do you experience discomfort or pain with any sexual activity?
YesNo

Has loss of bladder or bowel control affected your lifestyle?
YesNo

If you responded to "Yes" to one or more questions, you may be suffering from a pelvic floor condition. That is not a normal sign of aging.

Would you like to be contacted by a member of our women's health team to discuss your results? Enter your contact information below, and someone will be in touch.