Name
*
First Name
Last Name
Email Address
*
Did you have trouble healing after childbirth?
*
Yes
No
N/A
I don't know
Choose not to answer
Do you have frequent urinary tract infections?
*
Yes
No
N/A
I don't know
Choose not to answer
Do you experience pain during sexual intercourse
*
Yes
No
N/A
I don't know
Choose not to answer
Do you experience pain when having a pelvic exam?
*
Yes
No
N/A
I don't know
Choose not to answer
Do you experience pain with tampon use?
*
Yes
No
N/A
I don't know
Choose not to answer
Do you suffer from back, leg, groin, and/or abdominal pain?
*
Yes
No
N/A
I don't know
Choose not to answer
Do you lose urine when you cough, sneeze, and/or laugh?
*
Yes
No
N/A
I don't know
Choose not to answer
Do you lose urine when you lift, exercise, dance, and/or jump?
*
Yes
No
N/A
I don't know
Choose not to answer
Do you lose urine on the way to the bathroom?
*
Yes
No
N/A
I don't know
Choose not to answer
Do you have a strong urge to urinate?
*
Yes
No
N/A
I don't know
Choose not to answer
Do you lose urine when you hear water running?
*
Yes
No
N/A
I don't know
Choose not to answer
Do you experience pain and/or burning when you urinate?
*
Yes
No
N/A
I don't know
Choose not to answer
Do you have difficulty starting a stream of urine?
*
Yes
No
N/A
I don't know
Choose not to answer
Is it painful/do you strain when emptying your bladder?
*
Yes
No
N/A
I don't know
Choose not to answer
Do you feel like you can't empty your bladder fully?
*
Yes
No
N/A
I don't know
Choose not to answer
Do you suffer from a "falling out" feeling?
*
Yes
No
N/A
I don't know
Choose not to answer
Do you urinate more than 5 times a day?
*
Yes
No
N/A
I don't know
Choose not to answer
Do you strain when having bowel movements?
*
Yes
No
N/A
I don't know
Choose not to answer
Are your bowel movements painful?
*
Yes
No
N/A
I don't know
Choose not to answer
Do you suffer from leakage or stains?
*
Yes
No
N/A
I don't know
Choose not to answer
Do you take laxatives and/or enemas regularly?
*
Yes
No
N/A
I don't know
Choose not to answer
Do you leak gas by accident?
*
Yes
No
N/A
I don't know
Choose not to answer
