Pelvic Floor Screening Form
Thank you checking out my Pelvic Floor Screening Form.

This is a great way to check if you have any pelvic floor dysfunction, or at risk of developing it.

If you have any symptoms, I encourage you to get them checked out instead of adopting the good old Kiwi "she'll be right" response.

You can either read the form or check the boxes and submit it. I do not routinely check answers as this is for information purposes only, but pleas do get in touch if you have any questions or concerns at all!

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Have you ever been pregnant or given birth ? Vaginally or via C-section? *
Have you had a vacuum or forceps delivery, or a tear during childbirth? *
Have you ever undergone gynecological surgery or been diagnosed with a gynecological condition such as Endometriosis or PCOS? *
Have you had a hysterectomy? *
Have you ever injured your pelvic region (e.g. through a fall or pelvic radiotherapy)? *
Have you ever suffered from constipation or regularly strain on the toilet? *
Do you have a chronic cough or sneeze (e.g. because of asthma, smoking or hay fever?) *
Do you frequently lift heavy weights (e.g. at work or at the gym)? *
Do you currently, or have you ever leaked urine when you exercise, play sport, run, laugh, cough or sneeze? *
Is the urge to go to the toilet ever so strong that you would have to suddenly stop what you are doing and race to the toilet? *
Do you feel the urge to go to the toilet at certain times of the day? for example, putting your key in front door, hearing running water *
Do you constantly need to go to the toilet? *
Do you find it difficult to empty your bladder? does the bladder still feel like there is urine in it after you have emptied it? *
Does you ever leak urine after wiping or standing up from the toilet? *
Does it hurt to pass urine or pass a bowel movement? *
Do you accidentally lose control of you bowel – or accidentally pass wind? *
Do you feel like you have to wipe your bottom a lot to get clean after passing a bowel movement? or find staining in your underwear? *
Do you think you may have a prolapse (e.g. a bulge or feeling of heaviness, discomfort, pulling, dragging or dropping in the vagina)? *
Do you experience pelvic pain? or anywhere around the vulva/vagina? *
Do you experience pain with sex? *
Does sex feel different than it used to? Do you have sufficient lubrication when having sex? *
Have any female relatives experienced any of the symptoms above, or had surgery to manage the symptoms? *
Answering yes to any of the questions could potentially show signs of pelvic floor dysfunction. By making an appointment to see me, or your local Woman's Health Physio is the easiest way to know. There are heaps of things we can do to help you, you are not alone and we are here to listen and help!
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