Manage existing quizzes, Custom Templates, Better Security, Data Exports and much more

Sign inSign in with Facebook
Sign inSign in with Google
Make a Survey in Minutes. Use the webs #1 rated survey maker

Could I have a pelvic floor dysfunction?
 

I sometimes have pain in my vagina.
Yes
No
N/A
I sometimes experience the following urinary symptoms:
Accidental loss of urine
Feeling unable to completely empty my bladder
Having to void within a few minutes of a previous void
Pain or burning with urination
None of the above
I sometimes have a feeling of increased pelvic pressure or the sensation of my pelvic organs slipping down or falling out.
Yes
No
I have a history of pain in my low back, hip, groin, or tailbone or have had sciatica.
Yes
No
I experience the following bowel symptoms. (Select all that apply)
Loss of bowel control
Feeling unable to completely empty my bowels
Difficulty initiating a bowel movement
None of the above
Sexual activity increases one or more of my other symptoms.
Yes
No
Prolonged sitting increases my symptoms.
Yes
No
My most recent child...
Is in utero (I am currently pregnant)
is 0 to 6 weeks
is between 6 weeks and 6 months old
is 6 months to 1 year old
is between 1 year old to 5 years old
is Over 5 years old
What times of the day work better for most appointments?
Mornings (9am-12)
Afternoons (1-4pm)
Evening (5-8pm)
Late evening Telehealth (8-10pm)
Other
Where are you located? (City and State)
{"name":"Could I have a pelvic floor dysfunction?", "url":"https://www.survey-maker.com/QYPOSLT","txt":"I sometimes have pain in my vagina., I sometimes experience the following urinary symptoms:, I sometimes have a feeling of increased pelvic pressure or the sensation of my pelvic organs slipping down or falling out.","img":"https://www.survey-maker.com/3012/images/ogquiz.png"}