Pelvic Floor Health Assessment (PFHA) Survey

There are several pelvic floor conditions, each with its own set of symptoms

For example:

  • Stress Incontinence involves bladder leakage during physical activities like laughing, coughing, or exercising.
  • Overactive Bladder (OAB) refers to frequent urination, often with little warning.
  • Urge Incontinence is characterized by a sudden, strong urge to urinate that can be difficult to control.
  • Mixed Incontinence is a combination of multiple intcontinence types.
  • Fecal Incontinence Loss of bowel control, leading to accidental stool leakage.
  • Pain can stem from a variety of factors including, inflamation, tension in the pelvic floor, and sexual dysfunction.
  • Sexual Dysfunction includes conditions such as erectile dysfunction, pain during intimacy, and lack of sensation.

By taking this survey, it will help us better understand your pelvic floor symptoms so we can identifiy the most effective treatment protocol to address your issues. It's the first step toward lasting relief and a better quality of life.

Alphabetized by state. Available in AR, BB-Barbados, CA, CO, FL, ID, IL, MA, MD, MI, MN, NC, NY, OH, OR, PA, and SC.
1. Gender(Required)
Age Range(Required)
First Name(Required)
Last Name
Email(Required)
Zip Code(Required)
3. How long have you experienced your bladder leakage condition?
4. When do you experience bladder leakage?
5. How would you describe your bladder leakage condition?
6. How often do you have bladder leakage?
7. Do you experience excessive frequency (OAB-Over Active Bladder) to urinate?
8. How often do you use the bathroom at night?
9. Do you experience excessive urge to urinate?
10. If you experience an urge, how long can you control your bladder before you urinate?
11. How long have you experienced your bladder urge condition?
12. Do you have a prolapsed bladder and/or uterus?
13. What grade is your prolapse?
14. Do you suffer from fecal incontinence?
15. Do you experience pain in your pelvic floor?
16. Has a doctor diagnosed you with any of the following conditions as it relates to your pelvic floor pain?
17. Do you experience any sexual dysfunction?
18. What type of sexual dysfunction do you have?
19. Do you suffer from any of the following conditions?
20. Are you on any of the following medications?
21. Have you had surgery within your pelvic floor region?

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855 455-9283

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