Ashewell Pelvic Health Questionnaire

  • Ashewell Pelvic Health Questionnaire

    Please complete this brief questionnaire to help us assess your pelvic health before starting EMSELLA treatment.

  • Basic Information

    You got this ❤️
  • 1. What is your biological sex*
  • 4. Date of Birth*
     - -
  • Format: (000) 000-0000.
  • 6. Are you currently a patient at Ashewell Medical Group?*
  • 7. Preferred Contact Method*

  • Safety Screening

    Before we ask about your symptoms, we are going to ask you a few safety questions. If you answer "yes," to any of the safety questions, a member of our team will reach out to clarify if Emsella is right for you. 

  • Safety Screening - Section A: Implantable Devices & Metal

  • 8. Do you have a cardiac pacemaker, defibrillator, or neurostimulator?*
  • 9. Do you have any metal implants between your waist and thighs, including a copper IUD?*
  • 10. Do you have a chemo port, or any piercings between your waist and thighs that cannot be removed?*
  • 11. Do you have an implanted drug delivery pump (such as an insulin pump or pain pump)?*

  • Section B: Pregnancy

  • 13. Are you currently pregnant or is there a chance you could be pregnant?*

  • Section C: Cancer

  • 14. Do you currently have active cancer or a known tumor in your pelvic or abdominal area?*

  • Section D: Pelvic Organ Prolapse

  • 15. "Do you usually have a bulge or something falling out that you can see or feel in your vaginal area?"*

  • Section E: Surgical & Procedure History

  • 16. Do you have a history of abdominal/pelvic/genitourinary surgery (anything between your belly button and thighs)?*

  • Section F: Neurologic or Other

  • 18. Do you have a history of neurologic condition such as MS, Parkinson's disease, spinal cord injury or spina bifida?*
  • 19. Do you have a history of seizure disorder or epilepsy?*
  • 20. Do you have reduced or absent feeling in the pelvic area, buttocks, or upper thighs?*

  • Section G: Additional Questions

    Almost Done! We promise
  • 21. Do you have a bleeding disorder or are you taking a blood-thinning medication?*
  • 22. If you are male, are you currently experiencing a prostate or urinary tract infection? If you are female, do you currently have a vaginal or urinary tract infection?*
  • 23. Are there other medical conditions or health concerns we should be aware of before your EMSELLA treatment?*
  • Thank you for completing the safety screening. Based on your responses, we'd like to speak with you before proceeding. Please call us at (828)477-4077 and we'll help you find the right path forward.

  • Symptom Assessment

    The following questions help us to understand your current pelvic-floor symptoms. Answer based on how things have been for you over the last 4 weeks. 
  • 25. How often do you leak urine?*
  • 26. How much urine do you usually leak?*
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  • 29. When does leakage occur?*
  • 30. In the past 30 days, how satisfied have you been with your sex life?*
  • 31. How would you describe yourself over the past 6 months?
  • 32. How strong does your pelvic floor feel?*
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  • Should be Empty: