Please answer the following questions by circling the appropriate answer.
If you are unsure about how to answer a question, give the best answer you can. While answering these questions, please consider your symptoms over the last three months.
1. Do you experience pressure and/or pain in the lower abdomen, genital region and/or pelvis floor (often felt as heaviness, dullness or arousal/erectile dysfunction)?
2. Do you experience a strong sense of urgency and have to rush to the bathroom to have a bowel movement or urine discharge associated with a feeling of sphincter weakness?
3. Do you experience urine leakage (small amounts, drops even) related to coughing, sneezing, laughing, running, jumping and lifting weight?
4. How often does the fear of leaking urine or stool, and/or a bulging in the vagina (either the bladder, rectum or uterus falling out) cause you to restrict your sexual activity?
5. Compared to orgasams and erectile functions you have had in the past, how intense and functional are they now?
