Bladder
How many times per day do you typically urinate or how often do you urinate (frequency)? When you have to urinate, do you feel like you have to get to the toilet immediately (urgency)? What do you drink throughout the day (specifically, how much and what beverages)? What do you drink after dinner? Do you feel like you are emptying your bladder completely? Do you have difficulty starting the flow of urine? Do you have pain with urination? Do you ever experience urinary incontinence or leaking?
○ With coughing and sneezing? With standing from a chair? With exercise? ○ Do you ever have difficulty making it to the toilet in time? ○ Do you have incontinence during intercourse? ○ Are you ever incontinent at night while sleeping? ○ How often are you incontinent? ○ Do you wear a pad? If yes, how often do you change the pad?
How many times do you get up at night to urinate? Do you have frequent urinary tract infections?
Bowel
Are you constipated? How often do you have a bowel movement (BM)? Have you ever been diagnosed with irritable bowel syndrome (IBS)? Do you have to strain to empty? Do you ever have to push from your vagina in order to have a BM? Do you feel like you have to continue to wipe more than normal in order to get yourself clean? Are your stools hard or soft? Do you have pain during or after a BM?
Gynecologic
Are your periods regular? Do you have severe menstrual cramps? Did you have menstrual cramps during adolescence? What if any treatment did you have for that? Do you wear tampons? Is it painful to wear tampons? Are gynecologic exams painful for you? Have you ever been diagnosed with endometriosis? If yes, how was this diagnosis made? Do you have problems with chronic yeast infections? Are you sexually active? Do you have pain with intercourse?
○ With coughing and sneezing? With standing from a chair? With exercise? ○ When it is painful (initial penetration, deeper penetration)? ○ Do you have pain after intercourse? If so, how long does this last? ○ Is it painful when you orgasm?
Obstetric
How many times have you been pregnant? How many children have you had? What was the largest birth weight? Did you have significant back or pelvic pain during pregnancy? How long were you in labor? How long did you push? Did you have tearing or an episiotomy? Did the delivery require use of vacuum or forceps? Any complications during labor and delivery?
Psychiatric
Do you have a history of depression or anxiety? Have you ever been hospitalized for psychiatric illness? Have you ever had thoughts of killing yourself? Have you ever been the victim of abuse (physical, sexual, emotional, verbal)? Are you currently in an abusive relationship/situation?
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