How is your pelvic floor feeling?

1. Have you ever experienced urine leakage when coughing, laughing or sneezing?

Yes No

2. Have you ever experienced urine leakage while jumping, trampolining or running?

Yes No

3. Do you feel like you're going to the bathroom too often?

Yes No

4. Have you noticed that you go to the toilet for small urinations, that your bladder really isn't full?

Yes No

5. Do you feel an urge to go to the bathroom when you are in contact with water, washing your hands or when it's cold outside?

Yes No

6. Do you feel like you can't hold it in when you're almost home?

Yes No

7. Do you feel the urge to urinate when you're stressed?

Yes No

8. Do you feel any discomfort or heaviness in your pelvic floor?

Yes No

9. Do you experience pain in the perineum or pelvic area?

Yes No

10. Do you experience sexual pain?

Yes No

11. Do you experience diminished sensations in your sexuality?

Yes No

12. Do you suffer from chronic constipation?

Yes No

13. Are you experiencing menopausal symptoms?

Yes No

14. Are you in the post-partum period?

Yes No

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