Date of birth*

URINARY FREQUENCY - How many times do you pass urine in a the day?*

NOCTURIA - How many times do you get up in the night to pass urine?*

NOCTURNAL ENURESIS - Do you wet the bed before you wake up?*

URGENCY - Do you need to rush/hurry to pass urine when you get the urge?*

URGE INCONTINENCE - Does urine leak when you rush/hurry to the toilet/can you make it in time?*

STRESS INCONTINENCE - Do you leak with coughing, sneezing, laughing, exercise?*

WEAK STREAM - Is your urinary flow, prolonged or slow?*

INCOMPLETE BLADDER EMPTYING - Do you have a feeling of incomplete bladder emptying?*

PAD USAGE*

REDUCED FLUID INTAKE - Do you limit your fluid intake to decrease leakage?*

REDUCED FLUID INTAKE - Do you limit your fluid intake to decrease leakage?*

RECURRENT UTI - Do you have frequent bladder infections?*

DYSURIA - Do you have pain in your bladder/urethra when you empty your bladder?*

IMPACT ON SOCIAL LIFE - Does urine leakage affect your routine activities (recreation, shopping, etc)?*

How much does your bladder problem bother you?*

DEFAECATION FREQUENCY - How often do you usually open your bowels?*

CONSISTENCY OF BOWEL MOTION - How is the consistency of your usual stool?*

CONSISTENCY OF BOWEL MOTION - How is the consistency of your usual stool?*

DEFAECATION STRAINING - Do you have to strain a lot to empty your bowels?*

LAXATIVE USE - Do you use laxatives to empty your bowels?*

DO YOU FEEL CONSTIPATED? *

FLATUS INCONTINENCE - When you get wind/flatus, can you control it or does wind leak?*

FAECAL URGENCY - Do you get an overwhelming sense of urgency to empty your bowels?*

FAECAL INCONTINENCE WITH DIARRHOEA - Do you leak watery stool ?*

FAECAL INCONTINENCE WITH NORMAL STOOL - Do you leak normal stool when you don't mean to?*

INCOMPLETE BOWEL EVACUATION - Do you have the feeling of incomplete bowel emptying?*

OBSTRUCTED DEFAECATION - Do you use finger pressure to help emptying your bowel?*

How much does your bowel problem bother you?*

PROLAPSE SENSATION*

VAGINAL PRESSURE OR HEAVINESS - Do you experience vaginal pressure/heaviness/dragging sensations?*

PROLAPSE REDUCTION TO VOID - Do you have to push back your prolapse to help you void?*

PROLAPSE REDUCTION TO DEFAECATE - Do you have to push back your prolapse to help you empty your bowels?*

How bothered are you by your prolapse?*

SEXUALLY ACTIVE - Are you sexually active?

IF NOT, WHY NOT?

SUFFICIENT LUBRICATION - Do you have sufficient lubrication during intercourse?

VAGINAL SENSATIONS DURING INTERCOURSE:

VAGINAL LAXITY - Do you feel your vagina is too loose or lax?

VAGINAL TIGHTNESS/VAGINISMUS - Do you feel your vagina is too tight?

DYSPAREUNIA - Do you experience pain with intercourse?

DYSPAREUNIA - Do you experience pain with intercourse?

COITAL CONTINENCE - Do you leak urine during intercourse?

How much do these sexual issues bother you?