Pelvic Floor Health Assessment

Please fill out this evaluation as a preliminary step to help determine your bladder health and treatment options.

1. What is your gender?
2. What is your age range?
3. Do you experience one or both of the following?
Please note, there are two forms of bladder leakage...
Stress-Based causes leakage (questions 4-7)
Urge-Based is a constant pressure sensation on the bladder (questions 8-11)
4. If you experience bladder leakage, how long has it persisted?
5. If you experience bladder leakage, when does it occur?
(please select all that apply)
6. If you experience bladder leakage, how would you describe it?
7. If you experience bladder leakage, what is the frequency?
8. Do you experience a frequent urge to urinate?
9. If you experience an urge, how would you describe the intensity?

If you experience an urge, how long can you control your bladder before you urinate?

11. If you experience a bladder urge condition, how long has it persisted?
12. Do you currently use pads, liners, or diapers to manage your bladder condition?
13. Do you suffer from any of the following conditions?
(please select all that apply)
14. Are you on any of the following medications?
(please select all that apply)
15. Have you had surgery within your pelvic floor region?
(please select all that apply)
Thank you for taking the Bladder Control Assessment! Please enter your information below to receive your results.