pelvic floor confidential questionnaire

Full Name (required)

Your Email (required)

Name of Diagnosis (required)

Referred by (required)

Please describe your symptoms, including the precise area (required).

How and when did the problem start? How has it changed since it started (required)?

Have you had any past treatment for this condition? If yes, please describe (including whether it has changed your symptoms in any way)

What are your goals in coming to see me?

Please list dates of any pregnancies or births, with as much detail as you can:

How many times per day do you go to the toilet to pass urine? (required)

How many times do you wake up overnight to go to the toilet to pass urine? (required)

Please describe any difficulties with passing urine (required)

How often do you pass a bowel motion? (required)

Do you have any bowel problems or concerns? Please describe (required).

Please list any medical conditions or health concerns (required).

Please list any previous surgery including approximate dates (required).

Your occupation is (required).

Please enter your height:(required)

Please outline any current exercise that you do (required).

Is your weight stable, and are you comfortable with your fitness level (required)?