If Yes, please describe trauma: Pelvic Tumors or Yes ___ Yes ___ Pre ___ Post ___ Fibroids No ___ No ___ Yes ___ Yes ___ Peritonitis/Sepsis Pre ___ Post ___ No ___ No ___ Yes ___ Yes ___ Rectocele Pre ___ Post ___ No ___ No ___ Recurrent or Chronic Vaginal or Bladder Infections Yes ___ Yes ___ Pre ___ Post ___ If Yes, please specify No ___ No ___ location and nature of infections: Recurrent Vaginal Pain Yes ___ Yes ___ Pre ___ Post ___ If please Yes, No ___ No ___ describe the nature of pain experienced: Yes ___ Yes ___ Urinary Incontinence Pre ___ Post ___ No ___ No ___ Yes ___ Yes ___ Urinary Retention Pre ___ Post ___ No ___ No ___ Yes ___ Yes ___ Uterine Prolapse Pre ___ Post ___ No ___ No ___ Vaginal Vault Yes ___ Yes ___ Pre ___ Post ___ Prolapse No ___ No ___ Healing Problems Yes ___ Yes ___ Pre ___ Post ___ No ___ No ___ If Yes, please explain: Any other disease of the gut, intestines, or bowels Yes ___ Yes ___ Pre ___ Post ___ No ___ No ___ If Yes, please specify condition (s):
If Yes, please describe trauma: Pelvic Tumors or Fibroids Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Peritonitis/Sepsis Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Rectocele Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Recurrent or Chronic Vaginal or Bladder Infections If Yes, please specify location and nature of infections: Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Recurrent Vaginal Pain If Yes, please describe the nature of pain experienced: Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Urinary Incontinence Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Urinary Retention Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Uterine Prolapse Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Vaginal Vault Prolapse Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Healing Problems If Yes, please explain: Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Any other disease of the gut, intestines, or bowels If Yes, please specify condition (s): Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___
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