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 doctor for a referral. They should fax the referral to 860-358-2727

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?