*

First Name

Last Name

Do you usually experience pressure in the lower abdomen? *

0 No

1 Not at all

2 Somewhat

3 Moderately

4 Quite a bit

Do you usually experience heaviness or dullness in the lower abdomen? *

0 No

1 Not at all

2 Somewhat

3 Moderately

4 Quite a bit

Do you usually have a bulge or something falling out that you can see or feel in the vaginal area? *

0 No

1 Not at all

2 Somewhat

3 Moderately

4 Quite a bit

Do you usually have to push on the vagina, or around the rectum, to have a complete bowel movement? *

0 No

1 Not at all

2 Somewhat

3 Moderately

4 Quite a bit

Do you usually experience a feeling of incomplete bladder emptying? *

0 No

1 Not at all

2 Somewhat

3 Moderately

4 Quite a bit

Do you ever have to push on a bulge in the vaginal area with your fingers to start or complete urination? *

0 No

1 Not at all

2 Somewhat

3 Moderately

4 Quite a bit

Do you feel you need to strain too hard to have a bowel movement? *

0 No

1 Not at all

2 Somewhat

3 Moderately

4 Quite a bit

Do you feel you have not completely emptied your bowels at the end of a bowel movement? *

0 No

1 Not at all

2 Somewhat

3 Moderately

4 Quite a bit

Do you usually lose stool beyond your control if your stool is well formed? *

0 No

1 Not at all

2 Somewhat

3 Moderately

4 Quite a bit

Do you usually lose stool beyond your control if your stool is loose or liquid? *

0 No

1 Not at all

2 Somewhat

3 Moderately

4 Quite a bit

Do you usually lose gas from the rectum beyond your control? *

0 None

1 Not at all

2 Somewhat

3 Moderately

4 Quite a bit

Do you usually have pain when you pass your stool? *

0 No

1 Not at all

2 Somewhat

3 Moderately

4 Quite a bit

Do you experience a strong sense of urgency and have to rush to the bathroom to have a bowel movement? *

0 No

1 Not at all

2 Somewhat

3 Moderately

4 Quite a bit

Does part of your stool ever pass through the rectum and bulge outside during or after a bowel movement? *

0 No

1 Not at all

2 Somewhat

3 Moderately

4 Quite a bit

Do you usually experience frequent urination? *

0 No

1 Not at all

2 Somewhat

3 Moderately

4 Quite a bit

Do you usually experience urine leakage associated with a feeling of urgency; that is, a strong sensation of needing to go to the bathroom? *

0 No

1 Not at all

2 Somewhat

3 Moderately

4 Quite a bit

Do you usually experience urine leakage related to coughing, sneezing, or laughing?

0 No

1 Not at all

2 Somewhat

3 Moderately

4 Quite a bit

Do you usually experience small amounts of urine leakage (that is, drops)? *

0 No

1 Not at all

2 Somewhat

3 Moderately

4 Quite a bit

Do you usually experience difficulty emptying your bladder? *

0 No

1 Not at all

2 Somewhat

3 Moderately

4 Quite a bit

Do you usually experience pain or discomfort in the lower abdomen or genital region? *

0 No

1 Not at all

2 Somewhat

3 Moderately

4 Quite a bit