Is your pelvic floor tight?
Name
*
First Name
Last Name
Email
*
example@example.com
1. Do you experience leaking with sneezing, coughing, jumping, or heavy lifting?
Yes
No
2. Do you have difficulty starting to pee or fully voiding your bladder without pushing?
Yes
No
3. Do you experience constipation (having a bowel movement less than 3 times a week?)
Yes
No
4. Do you have to rush / hurry to to pass urine when you get the urge?
Yes
No
5. Do you frequently experience air escaping from the vagina (queef)?
Yes
No
6. Do you have difficulty with strength, coordination and control of the pelvic floor muscles?
Yes
No
Not sure
7. Do you have pain in other parts of the body like in the sacro-iliac joint, the hips or the low back?
Yes
No
8. Do you experience frequent UTIs?
Yes
No
9. Do you experience tailbone pain?
Yes
No
10. Do you experience pain with penetration either sexual or non sexual (ex: pelvic exam or tampons)?
Yes
No
11. Do you experience pain with or after orgasm?
Yes
No
12. Do you have difficulty taking a deep breath in?
Yes
No
13. If you tried doing the Kegel exercise before, did your symptoms get better or worse?
Worse
Better
Unsure/haven't tried
14. Have you ever had the feeling that your tampon is falling out or have had your tampon fall out?
Yes
No
Total point is
Submit
Should be Empty: