Name *

First Name

Last Name

Date

What is the date of your pregnancy loss?

MM

DD

YYYY

Did you experience any pelvic floor or pelvic health issues after your loss? Please mark any and all that apply to your situation.

Bladder sensitivity when going to the bathroom.

Heaviness around the base of my pelvis/pelvic floor.

Difficulty going to the bathroom (pee or poop).

Difficulty making it to the bathroom (urinary or fecal incontinence).

Pelvic pain (Si-joint, low back or hip pain).

Painful sex.

Numbness during sex (little to no sensation).

Heavy bleeding/cramping before or during menstrual cycle.

When do you notice your pelvic floor or pelvic health issues the most? Please mark any and all that apply to your current situation.

Any time throughout the day, including resting or lying down.

First thing in the morning or right before bed.

When I’m sitting upright.

When I’m going to the bathroom or using the bathroom.

During sex or after sex.

During light to moderate physical activity, such as house chores or light walking.

During moderate to heavy physical activity, such as workouts, running or heavy lifting.

Before or during my menstrual cycle.