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Serving the Bayside Community for 30 Years

Women’s Health Questionnaire

Women’s Health Questionnaire

Please fill in and submit this form and one of our qualified Physiotherapists will contact you shortly with advice regarding your suitability for our program at SSM.

Please answer all questions, marking the most appropriate answer.

Basic Information
Personal History
Childbirth Experiences
  • Vaginal Delivery
  • Tears/Episiotomy
  • Forceps
  • Caesarean Section
Past Medical History
  • Cancer
  • Thyroid Problems
  • Heart Condition
  • Cystitis
  • Diabetes
  • Anxiety/Depression
  • Respiratory Problems
  • Infections/skin problems
  • Spinal Problems
  • Allergy
  • Epilepsy
  • Mobility Problems
  • Hearing Problems
  • Eyesight Problems
  • Conditions affecting your nerves or brain
Bladder Function
  1. 19. How many times do you pass urine in the day?
    • up to 7
    • between 8-10
    • between 11-15
    • more than 15
  2. 20. How many times do you get up at night to pass urine?
    • 0 - 1
    • 2
    • 3
    • more than 3
  3. 21. Do you wet the bed before you wake up at night?
    • never
    • occasionally (less than once per week)
    • frequently (once or more per week)
    • always (every night)
  4. 22. Do you need to rush or hurry to pass urine when you get the urge?
    • can hold on
    • occasionally have to rush (less than once per week)
    • frequently have to rush (once or more per week)
    • daily
  5. 23. Does urine leak when you rush or hurry to the toilet or you can't make it in time?
    • not at all
    • occasionally (less than once per week)
    • frequently (once or more per week)
    • daily
  6. 24. Does urine leak when coughing, sneezing, laughing or exercising?
    • not at all
    • occasionally (less than once per week)
    • frequently (once or more per week)
    • daily
  7. 25. Is your urinary stream (urine flow) weak, prolonged or slow?
    • never
    • occasionally (less than once per week)
    • frequently (once or more per week)
    • daily
  8. 26. Do you have a feeling of incomplete bladder emptying?
    • never
    • occasionally (less than once per week)
    • frequently (once or more per week)
    • daily
  9. 27. Do you need to strain to empty your bladder?
    • never
    • occasionally (less than once per week)
    • frequently (once or more per week)
    • daily
  10. 28. Do you have to wear pads because of urinary leakage?
    • never
    • as a precaution
    • when exercising / during a cold
    • daily
  11. 29. Do you limit your fluid intake to decrease urinary leakage?
    • never
    • before going out
    • moderately
    • always
  12. 30. Do you have frequent bladder infections?
    • no
    • 1-3 per year
    • 4-12 per year
    • more than one per month
  13. 31. Do you have pain in your bladder or urethra when you empty your bladder?
    • never
    • occasionally (less than once per week)
    • frequently (once or more per week)
    • daily
  14. 32. Does the urine leakage affect your routine activities like recreation, socialising, sleeping, shopping etc?
    • not at all
    • slightly
    • moderately
    • greatly
  15. 33. How much does your bladder problem bother you?
    • not at all
    • slightly
    • moderately
    • greatly
Bowel Function
  1. 34. How often do you usually open your bowels?
    • every other day or daily
    • less than every 3 days
    • less than once a week
    • more than one a day
  2. 35. How is the consistency of your usual stool?
    • soft
    • firm
    • hard (pebbles)
    • watery
    • variable
  3. 36. Do you have to strain a lot to empty your bowels?
    • never
    • occasionally (less than once per week)
    • frequently (once or more per week)
    • daily
  4. 37. Do you use laxatives to empty you bowels?
    • never
    • occasionally (less than once per week)
    • frequently (once or more per week)
    • daily
  5. 38. Do you feel constipated?
    • never
    • occasionally (less than once per week)
    • frequently (once or more per week)
    • daily
  6. 39. When you get wind or flatus, can you control it, or does wind leak?
    • never
    • occasionally (less than once per week)
    • frequently (once or more per week)
    • daily
  7. 40. Do you get an overwhelming sense of urgency to empty your bowels?
    • never
    • occasionally (less than once per week)
    • frequently (once or more per week)
    • daily
  8. 41. Do you leak watery stool when you don't mean to?
    • never
    • occasionally (less than once per week)
    • frequently (once or more per week)
    • daily
  9. 42. Do you leak normal stool when you don't mean to?
    • never
    • occasionally (less than once per week)
    • frequently (once or more per week)
    • daily
  10. 43. Do you have a feeling of incomplete bowel emptying?
    • never
    • occasionally (less than once per week)
    • frequently (once or more per week)
    • daily
  11. 44. Do you have to use finger pressure to help empty your bowels?
    • never
    • occasionally (less than once per week)
    • frequently (once or more per week)
    • daily
  12. 45. How much does your bowel problem bother you?
    • not at all
    • slightly
    • moderately
    • greatly
Prolapse Symptoms
  1. 46. Do you have a sensation of tissue protrusion or a lump or bulging in your vagina?
    • never
    • occasionally (less than once per week)
    • frequently (once or more per week)
    • daily
  2. 47. Do you experience vaginal pressure or heaviness or a dragging sensation?
    • never
    • occasionally (less than once per week)
    • frequently (once or more per week)
    • daily
  3. 48. Do you have to push back your prolapse in order to void?
    • never
    • occasionally (less than once per week)
    • frequently (once or more per week)
    • daily
  4. 49. Do you have to push back your prolapse to empty your bowels?
    • never
    • occasionally (less than once per week)
    • frequently (once or more per week)
    • daily
  5. 50. How much does your prolapse bother you?
    • not applicable. I do not have a prolapse
    • not at all
    • slightly
    • moderately
    • greatly
Sexual Function
  1. 51. Are you sexually active?
    • no
    • less than once per week
    • once or more per week
    • daily or most days

    2. If you are not sexually active, please continue to answer questions 52 and 60 only

  2. 52. If you are not sexually active, please tell us why:
    • Do not have a partner
    • I am not interested
    • My partner is unable
    • Vaginal dryness
    • Too painful
    • Embarrassment due to the prolapse or incontinence
    • Other reason:
  3. 53. Do you have sufficient natural vaginal lubrication during intercourse?
    • yes
    • no
  4. 54. During intercourse vaginal sensation is:
    • normal/pleasant
    • minimal
    • painful
    • none
  5. 55. Do you feel that your vagina is too loose or lax?
    • never
    • occasionally
    • frequently
    • always
  6. 56. Do you feel that your vagina is too tight?
    • never
    • occasionally
    • frequently
    • always
  7. 57. Do you experience pain with sexual intercourse?
    • never
    • occasionally
    • frequently
    • always
  8. 58. When does the pain during intercourse occur?
    • not applicable, I do not have pain
    • at the entrance to the vagina
    • deep inside, in the pelvis
    • both at the entrance and in the pelvis
  9. 59. Do you leak urine during sexual intercourse?
    • never
    • occasionally
    • frequently
    • always
  10. 60. How much do these sexual issues bother you?
    • not applicable, I do not have problems
    • not at all
    • slightly
    • moderately
    • greatly

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Cancellation Policy

To be fair to both patients seeking appointments, and our staff, we would appreciate 24 hours notice when cancelling or rescheduling your appointments. We send SMS texts the day prior as your reminder. Failure to adequately notify us may result in full fees being charged.

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Sandringham Sports Medicine

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while achieving exceptional clinical results.

We will accomplish this by selecting motivated and
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Pilates Classes Available

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Pilates Timetable for 2012


Monday 1:00pm -1:45pm
Monday 7:45pm - 8:30pm
Tuesday 1:00pm -1:45pm
Tuesday 7:45pm - 8:30pm
Wednesday 7:30am - 8:15am
Wednesday 1:00pm -1:45pm
Wednesday 7:00pm - 7:45pm
Wednesday 7:45pm - 8:30pm
Thursday 1:00pm -1:45pm
Thursday 7:45pm - 8:30pm
Friday 1:00pm -1:45pm
Saturday 10:00am - 10:45am
Saturday 2:00pm - 2:45pm
Saturday 2:45pm - 3:30pm



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