Pre/Post-Prostatectomy Questionnaire

Please take a few moments to read through these questions and answer yes to any that apply to you. Don't hesitate to get in touch with H&D Physical Therapy to ask about pelvic health therapy.  If you answered ‘Yes’ to any of the symptoms outlined in this survey, it is important to speak to your doctor or a continence professional, as these symptoms can be assessed and treated. You don't have to put up with them.

Name *

First

Last

Email *

Phone *

Do you have bladder or bowel control problems after surgery for prostate cancer or prostate enlargement? *

• Yes
• No

Do you have bladder or bowel control problems after pelvic radiotherapy/radiation? * *

• Yes
• No

Do you have persistent pain in your pelvic area (e.g. bladder, penis, testes/scrotum, between the scrotum and anus)? *

• Yes
• No

Ever leak urine when you exercise, play sport, laugh, cough or sneeze? *

• Yes
• No

Need to get to the toilet in a hurry or not make it there in time? *

• Yes
• No

Get up more than once a night to urinate? *

• Yes
• No

Have problems controlling the contents of your bowel? *

• Yes
• No

Find it difficult to empty your bladder or bowel? *

• Yes
• No

Frequently have pain when you urinate, ejaculate or defaecate? *

• Yes
• No

Submit