Self-Assessment Questionnaire
If you answer YES to any of these questions, you could have a bowel, bladder and/or pelvic pain problem that may benefit from Middlesex Health’s Pelvic Health and Incontinence Training Program.
Referral Process for the PHIT Program
1. Ask your provider for a referral. They should fax the referral to 860-358-2727 or submit a referral through EPIC
2. Call 860-358-2700 to schedule your appointments
For more information or to speak with a PHIT specialist call 860-358-2700
BLADDER SELF-ASSESSMENT QUESTIONNAIRE
Do you:
- Leak or wet yourself when you stand up, cough, laugh or sneeze?
- Feel an uncomfortable urge to urinate?
- Sometimes wear pads to absorb urine, or “just in case?”
- Wake up more than twice during the night to use the toilet?
- Sometimes feel your bladder is not quite empty?
- Often feel anxious because you think you might not make it to the toilet in time?
BOWEL SELF-ASSESSMENT QUESTIONNAIRE
Do you:
- Leak when you stand up, cough, laugh or sneeze?
- Have to push or strain during bowel movements?
- Have pain during bowel movements?
- Have accidental bowel movements after a meal or beverage?
PELVIC PAIN SELF-ASSESSMENT QUESTIONNAIRE
Do you:
- Have pelvic, rectal, vaginal or genital pain, numbness or tingling at any time?
- Have pain in the area of your pubic bone, hips, abdomen?
- Have pain with dilation or after gender confirming surgeries?
PREGNANCY/POSTPARTUM SELF ASSESSMENT QUESTIONNAIRE
Do you:
- Have pubic bone, sacrum, hip or back pain since becoming pregnant or postpartum?
- Have you been told you have Diastasis Reci?
- Have pain with return to intimacy?