Women's Health Screening Questionnaire

  • Women's Health Screening Questionnaire

  • All responses will be treated in strict confidence, held securely (password protected) and will be destroyed after 6 months. 

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  • Date of Birth
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  • Health Screening Questions

  • Has your doctor ever said that you have a heart condition AND that you should only do exercise recommended by your doctor?
  • Do you feel pain in your chest when you do physical activity?
  • In the past month, have you had chest pain when you are not doing physical activity?
  • Do you lose your balance because of dizziness or do you ever lose consciousness?
  • Do you have a bone or joint problem that could be made worse by a change in your physical activity
  • Is your doctor currently prescribing drugs for your blood pressure or heart condition?
  • Are you diabetic?
  • Are you experiencing difficulty controlling bowel movements, wind or urinary urges?
  • Do you lose urinary control when laughing, sneezing, coughing or jumping or moving quickly?
  • Are your bowel movements or urination painful?
  • Do you experience a feeling of heaviness in your pelvis? Or has anyone ever suggested you may have a prolapse?
  • Do you currently or have you ever needed to wear incontinence pads?
  • Do you experience pelvic pain e.g. lower back, vaginal area, ower abdomen/ pelvis?
  • Are you going through peri-menopause, or are you post-menopause?
  • Have you ever undergone any gynaecological surgery (e.g. hysterectomy, prolapse repair, fibroids removal)?
  • Are you or have you ever been an elite athlete? Runner, gymnast, trampolining or any sport that involved regular contact?
  • Do you have a history or low back pain or any other type of back pain?
  • Have you ever sustained an injury to your pelvic region (fracture, radiotherapy or injury to your coccyx?)
  • Do you suffer from constipation or regularly strain on the toilet?
  • Do you have a chronic cough or a condition that affected your breathing (smoking, hayfever, asthma?)
  • Are you or have you been overweight?
  • Do you frequently lift heavy weights (Gym, work, children, caring for disabled or elders?)
  • Are you incontinent overnight?
  • Do you experience pain that is unrelenting, even overnight?
  • Are you currently undergoing or previously undergone treatment for cancer?
  • Which services at Michelle Brown Women's Wellness are you interested in finding out more about?
  • Should be Empty: