Pelvic Floor Screening Form Name Date

Pelvic Floor Screening Form
Please answer the following questions to help us assess your pelvic floor function:
Name _______________________________________________ Date ___________________________
Urinary Function
1. How many times per day do you urinate?
2. How many times do you wake up to urinate at night?
3. Do you experience a sudden urge to urinate?
If yes, what triggers it? _____________________________
4. Do you experience difficulty starting your urine stream?
5. Do you have a weak or slow urine stream?
6. Do you feel unable to completely empty your bladder?
7. Do you experience pain or burning with urination?
8. Do you experience unintentional urinary leakage?
If yes, what triggers it? ____Coughing ____Laughing ____Sneezing
____ Jumping ____Lifting ____Exercise ____Urgency ____Position
changes ____ Running water ____ Cold ____Other: _________________
9. Do you use protective pads? If so, what kind?
Bowel Function
10. Have you ever experienced fecal incontinence?
11. Do you have a history of constipation or straining to have a
bowel movement?
12. Do you experience uncontrollable gas?
13. Do you use laxatives or digestive supplements?
If so, what kind? _______________________________________
Fluid Intake
14. Approximately how much fluid (in ounces) do you drink per
15. What types of fluid do you typically consume? (check all that apply)
____ Water ____ Coffee ____Tea ____ Juice ____ Diet Drinks ____ Soda
____ Other: _______________________________________________________________
16. Do you consume caffeine daily?
If so, how many cups? ______________
Pelvic Floor Function
17. Have you ever been instructed in pelvic floor exercises, or
18. Do you perform Kegels on a regular basis?
Sexual Function
19. Do you experience pain with sexual penetration?
20. Do you have a history of sexual trauma?
Reproductive History
21. Are you currently pregnant?
If so, what is your due date?______________________
22. How many full term pregnancies have you had? ________
________ Vaginal Deliveries ________Caesarean Sections
23. Did you have an episiotiomy?
24. Were there any delivery complications?
If yes, please explain: _________________________________________________