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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
*
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Name
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Δ
*denotes required answer.
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