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Pelvic Health

Did you know that over 40% of women in the US are affected by bladder and bowel problems? Did you know that women are at a higher risk of these problems due to aging, childbirth, trauma, menopause, heavy lifting or obesity? This questionnaire has been developed with you in mind and for a healthy and active lifestyle. After submitting the questionnaire, the Women’s Health Navigator will contact you, assist in answering questions, and connect you with healthcare providers trained in this special area of women’s health.

Sources: and

* Indicates required information
Name  * 
Email Address  * 
Phone  * 
Please answer the questions below, if you answer yes please tell us how much it bothers you 
Do you usually experience frequent urination? 
Do you have difficulty starting or maintaining your stream? 
Do you get up two or more times at night to urinate? 
Are you using the restroom so often it disrupts your day? 
Do you find it hard to make it to the bathroom, occasionally leaking urine? 
Are you using pads or other forms of protection to absorb bladder leakage? 
Do you sometimes leak urine while sneezing, coughing, lifting heavy objects or even laughing?  
Do you have pain as your bladder fills and decreased pain after voiding? 
Do you suffer from pelvic pain or experience pain during or after intercourse? 
Do you leak stool or gas between bowel movements beyond your control? 
Do you have difficulty emptying stool from your rectum, causing you to strain and push? 
Do you experience a strong sense of urgency and have to rush to the bathroom to have a bowel movement?  
Are you experiencing pressure or a bulging sensation in your lower abdomen or pelvis, especially after standing for long periods of time?  
Do you have a feeling of fullness or heaviness like something isfalling out of your vagina or rectum? 
Have tampons become too uncomfortable to use or do they fall out? 
If you answered yes to any of the questions above, does it affect your: 
ability to do household chores (cooking, housecleaning, laundry)? 
ability to do physical activities such as walking, swimming, or other exercise? 
entertainment activities such as going to a movie or concert? 
ability to travel by car or bus for a distance greater than 30 minutes away from home? 
participating in social activities outside your home? 
participating in social activities outside your home? 

For more information, please contact:

Patricia Reggio MSN, RN
Women’s Health Navigator
FMH Crestwood
7211 Bank Court
Frederick, MD 21703 240-215-1447



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