1. Do you usually experience pressure in the lower abdomen?

2. Do you usually experience heaviness in the lower abdomen?

3. Do you usually have a bulge or something falling out that you can see or feel in your vaginal area?

4. Do you ever have to push on the vagina or around the rectum to have a complete bowel movement?

5. Do you usually experience a feeling of incomplete bladder emptying

6. Do you ever have to push up on the bulge in the vaginal area with your fingers to start or complete urination?

7. Do you feel you need to strain too hard to have a bowel movement?

8. Do you feel you have not completely emptied your bowels at the end of a bowel movement?

9. Do you usually lose stool beyond your control if your stool is well formed?

10. Do you usually lose stool beyond your control if your stool is loose?

11. Do you usually lose gas from your rectum beyond your control?

12. Do you usually have pain when you pass stool?

13. Do you experience a strong sense of urgency and have to rush to the bathroom to have a bowel movement?

14. Does part of your bowel ever pass through the rectum and bulge outside during or after bowel movement?

15. Do you usually experience frequent urination?

16. Do you usually experience urine leakage associated with a feeling of urgency, that is, a strong sensation of needing to go to the bathroom?

17. Do you usually experience urine leakage related to coughing, sneezing, or laughing?

18. Do you usually experience small amounts of urine leakage (that is, drops)?

19. Do you usually experience difficulty emptying your bladder?

20. Do you usually experience pain or discomfort in the lower abdomen or genital region?