• Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Please answer these questions so that we can better help to address your pelvic heatlh and or sexual health concerns:

  • Are you currently pregnant?*
  • Any tearing?*
  • Do you have vaginal dryness?*
  • Do you use any personal lubricants*
  • Do you have pain with vaginal or anal intercourse?*
  • Do you use any type of lubricant for intercourse?*
  • Do you suffer from prolapse of any of the organs of your pelvis?
  • Do you have urinary incontinence?*
  • Do you have burning with urination?*
  • Do you have chronic vaginal discharge?*
  • Do you wear cotton underwear always?*
  • Do you sleep without underwear?*
  • Are you able to have an orgasm with foreplay?*
  • Are you able to have an orgasm with vaginal or anal penetration?*
  • Please look at/draw on the Bristol Stool Chart to describe the shape and consistency of your BM
  • Do you have fecal incontinence?*
  • Do you suffer from constipation?*
  • Do you exercise regularly?*
  • Do you smoke?*
  • Do you drink carbonated beverages?*
  • Please explain any symptoms you are having and mark on diagram if appropriate
  • Should be Empty: