Pelvic Floor Health QuestionnairePelvic Floor Health QuestionnairePelvic Floor Health QuestionnairePlease answer all questions. Name Contact Phone Number Today's Date Do you experience difficulties with control of bowel, wind or urine urges? Yes NoIf yes, please add details in the box at the end. Do you lose urine when laughing, sneezing, coughing or moving suddenly? Yes NoIf yes, please add details in the box at the end. Do you find the need to urinate comes on urgently and quite frequently during the day? Yes NoIf yes, please add details in the box at the end. Do you have bladder discomfort or pain meaning that you have to empty your bladder ASAP? Yes NoIf yes, please add details in the box at the end. Is it painful when you open your bowels or urinate? Yes NoIf yes, please add details in the box at the end. Do you have a sense of fullness in your vagina or rectum or have you been diagnosed with Prolapse? Yes NoIf yes, please add details in the box at the end. Have you ever had a baby? Please give details of any injuries caused by childbirth. Yes NoIf yes, please give details of any injuries caused by the childbirth? Are you pre, peri or post menopause? Yes NoIf yes, please add details in the box at the end. Do you have a history of lower back pain? Yes NoIf yes, please add details in the box at the end. Do you have constipation? Yes NoIf yes, please add details in the box at the end. Do you experience pain with intercourse or sexual stimulation Yes NoIf yes, please add details in the box at the end. Have you ever had any kind of pelvic injury or had radiotherapy to the pelvis? Yes NoIf yes, please add details in the box at the end. Do you do frequent heavy lifting: at the gym/at work/children or caring for others? Yes NoIf yes, please add details in the box at the end. Further Details About Relevant Medical Issues Confidentiality: Information you enter here is sent to us in a password protected file then securely stored in Dropbox. For more details see our Privacy and Cookies page. SubmitΔ