Symptomology Questionnaire
Please answer the following questions to help assess your pelvic floor and intimate wellness symptoms.
Pelvic Floor / Incontinence Symptoms
Please answer Yes or No to each of the following:
Do you leak urine when coughing, laughing, sneezing, or jumping?
*
Yes
No
Do you have trouble getting to the restroom before leaking?
*
Yes
No
Do you wear feminine protection pads regularly?
*
Yes
No
Do you urinate frequently (more than 8 times per day)?
*
Yes
No
Do you wake up multiple times at night to urinate?
*
Yes
No
Do you experience a sudden, urgent need to urinate?
*
Yes
No
Do you have difficulty emptying your bladder completely and experience dripping when you stand up?
*
Yes
No
Do you feel you have weak pelvic floor muscles?
*
Yes
No
Do you experience pelvic pressure or heaviness?
*
Yes
No
Intimate Wellness Symptoms
Please answer Yes or No to each of the following:
Do you experience vaginal dryness?
*
Yes
No
Do you experience vaginal itching or irritation?
*
Yes
No
Do you experience vaginal laxity or looseness?
*
Yes
No
Do you have reduced vaginal sensation?
*
Yes
No
Do you experience pain during intercourse?
*
Yes
No
Do you experience discomfort during intimacy?
*
Yes
No
Do you have decreased sexual satisfaction?
*
Yes
No
Do you have decreased libido or sex drive?
*
Yes
No
Do you experience sexual dysfunction?
*
Yes
No
Do you have difficulty achieving orgasm?
*
Yes
No
Do you have reduced confidence in intimate situations?
*
Yes
No
Would you like to book a physician consult?
Name
First Name
Last Name
What is the best way to reach you?
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