Women’s Pelvic Health Screening

This screening questionnaire is designed to help you assess your symptoms. These questions are not intended to diagnose pelvic floor disorders but to help you decide whether you should see a specialist.

Do you experience urinary leakage:

Yes   No With coughing, sneezing, laughing?
Yes   No With exercise, running or jumping?
Yes   No Do you have accidental bowel leaks?
Yes   No Do you experience a sudden urge to go to the bathroom and find you can't get there on time?
Yes   No Do you wear liners or pads to protect your clothing from urine leakage?
Yes   No Do you urinate more than 2 times per night?
Yes   No Do you have bowel or urine accidents while asleep?
Yes   No Do you have a feeling of a bulge, fullness or heaviness in the pelvic area, especially when you urinate or have a bowel movement?
Yes   No Do you have pelvic pain or discomfort?
Yes   No Do you experience vaginal dryness?
Yes   No Do you experience discomfort or pain with sexual activity?
Yes   No Has loss of bladder or bowel control affected your lifestyle?

If you checked “Yes” to one or more questions, you may be suffering from a pelvic floor condition. This is not a normal sign of aging.

Personal Information

First Name* Last Name*
Phone Number*

Would you like to be contacted by a member of our women's health services team to discuss the results?

Yes   No