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Pelvic Health Quiz

Are you Male, Female or Non-Binary?*
- Male
- Female
- Non-Binary
1. Is there a delay before you can start to urinate?*
- Never
- Occasionally
- Sometimes
- Most of the time
- All of the time
2. Do you have to strain to continue urinating?*
- Never
- Occasionally
- Sometimes
- Most of the time
- All of the time
3. What would you say the strength of your urinary stream is?*
- Normal
- Occasionally reduced
- Sometimes reduced
- Reduced most of the time
- Reduced all of the time
4. Do you have a sudden need to rush to the toilet to urinate?*
- Never
- Occasionally
- Sometimes
- Most of the time
- All of the time
5. Does urine leak when you cough or sneeze?*
- Never
- Occasionally
- Sometimes
- Most of the time
- All of the time
6. How often do you pass urine during the day?*
- 1-6 times
- 7-8 times
- 9-10 times
- 11-12 times
- 13 or more times
7. During the night, how many times do you get up to urinate, on average?*
- None
- One
- Two
- Three
- Four or more
8. Do you ever have groin or pelvic floor pain?*
- Never
- Occasionally
- Sometimes
- Most of the time
- All of the time
9. Do you have regular bowel movements?*
- Never
- Occasionally
- Sometimes
- Most of the time
- All of the time
10. Do you have sexual dysfunction or pain with sexual activity?*
- Never
- Occasionally
- Sometimes
- Most of the time
- All of the time
Adapted from The International Continence Society*
1. Do you have a sudden need to rush to the toilet to urinate?*
- Never
- Occasionally
- Sometimes
- Most of the time
- All of the time
2. How often do you pass urine during the day?*
- 1-6 times
- 7-8 times
- 9-10 times
- 11-12 times
- 13 or more times
3. During the night, how many times do you get up to urinate, on average?*
- None
- One
- Two
- Three
- Four or more
4. Do you have regular bowel movements?*
- Never
- Occasionally
- Sometimes
- Most of the time
- All of the time
5. Do you have pain with sexual activity?*
- Never
- Occasionally
- Sometimes
- Most of the time
- All of the time
6. Do you ever have groin or pelvic floor pain?*
- Never
- Occasionally
- Sometimes
- Most of the time
- All of the time
6. Do you have painful periods?*
- Yes
- No
7. Do you feel pain or heaviness in the Pelvic Floor?*
- Yes
- No
8. If you have been pregnant, did you have any of the following?*
- Complications during pregnancy/postpartum
- Episiotomy
- Cesarean Birth
- Leakage of Urine during pregnancy or in the postpartum period
- Not Applicable
Select all that apply
Are you 18 years or older?*
- Yes
- No
What is your First Name?*
What is your Last Name?*
Email Address*
- By clicking this box you agree to receive email communication from Athletico Physical Therapy
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Athletico Physical Therapy cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, edad, religión, sexo, origen nacional, condición socioeconómica, orientación sexual, identidad o expresión de género, discapacidad, condición de veterano o fuente de pago. Serás tratado con dignidad, compasión y respeto como individuo.

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