Pregnancy & Post-Partum Care Questionnaire

Name *

First

Last

Email *

Phone *

I sometimes have pelvic pain (in genitals, perineum, pubic or bladder area, or pain with urination) that exceeds a '3' on a 1-10 pain scale, with 10 being the worst pain imaginable. *

I sometimes experience one or more of the following urinary symptoms: *

Accidental loss of urine
Feeling unable to empty bladder
Having to void within a few minutes of previous void
Pain or burning during urination
Difficulty starting or frequent stop/starting of urine stream
None of these apply

I often or occasionally have to get up to urinate two or more times at night *

I sometimes have a feeling of increased pelvic pressure or the sensation of my pelvic organs slipping down or falling out. *

I have a history of pain in my low back, hip, groin, or tailbone or have had sciatica. *

I sometimes experience one or more of the following bowel symptoms: *

Loss of bowel control
Feeling unable to completely empty my bowels
Straining or pain with bowel movement
Difficulty initiating a bowel movement
None of these apply

I sometimes experience pain or discomfort with sexual activity or intercourse. *

Sexual activity increases one or more of my symptoms. *

Prolonged sitting increases my symptoms. *

Pregnancy & Post-Partum Care Questionnaire

Please check all that apply to you

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