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✓ Patient Information
1 Bladder Control
Leakage, urgency, or frequency
Do you have accidental loss of urine, or urinary urgency/frequency?
months
years
Do you use pads for lost urine?
Ever wet the bed while asleep?
Times you can't make it in time?
Does running water trigger loss?
Which best describes your urine loss? (check all that apply)
Have you seen a physician for urine loss?
Surgery for urinary leakage?
Taken medication to prevent urine loss?
2 Bladder Emptying
Do you have problems urinating or emptying your bladder completely?
months
years
Dribbling after you stand?
Difficulty starting your stream?
Assume abnormal positions to urinate?
Strain to empty?
Feel empty after passing urine?
Is your urine flow:
3 Prolapse / Vaginal Support
Do you have fullness, pressure, or a bulge/protrusion of vaginal tissue?
months
years
Do you notice a bulge?
Worse at day's end / after standing?
Push it back to empty bladder/bowel?
Ever used a pessary?
Surgery to repair prolapse?
4 Bowel Symptoms
Do you have problems with your bowels — incontinence or difficulty emptying?
months
years
Accidental loss of solid stool?
Accidental loss of liquid stool?
Accidental loss of gas?
Wear protective pads?
Constipation?
Diarrhea?
Bloating?
Frequent desire to move bowels?
Feel bowels never completely empty?
Use fingers to help a bowel movement?
Seen a physician for bowel symptoms?
5 Sexual History
Are you sexually active?
If not active, are barriers due to:
6 Pelvic Pain
Do you have pain in your pelvic area?
Where is your pain? (check all that apply)
months
years
Relieved by emptying your bladder?
Pain with urination?
See a pain specialist?
Does anything relieve the pain?