Yes ___ Yes ___ Cystocele Pre ___ Post ___ No ___ No ___ Yes ___ Yes ___ Diabetes Pre ___ Post ___ No ___ No ___ Yes ___ Yes ___ Diverticulitis Pre ___ Post ___ No ___ No ___ Yes ___ Yes ___ Dyspareunia Pre ___ Post ___ No ___ No ___ Yes ___ Yes ___ Enterocele Pre ___ Post ___ No ___ No ___ Yes ___ Yes ___ Fistulas Pre ___ Post ___ No ___ No ___ Yes ___ Yes ___ Hernias Pre ___ Post ___ No ___ No ___ Hypertension or High Yes ___ Yes ___ Pre ___ Post ___ Blood Pressure No ___ No ___ Hypotension or Low Yes ___ Yes ___ Pre ___ Post ___ Blood Pressure No ___ No ___ Immune System Disease or Dysfunction including HIV/AIDS Yes ___ Yes ___ Pre ___ Post ___ No ___ No ___ If please specify Yes, condition: Yes ___ Yes ___ Malnutrition Pre ___ Post ___ No ___ No ___ Muscle or Disorder Yes ___ Yes ___ Pre ___ Post ___ No ___ No ___ If Yes, please specify disorder: Neuromuscular Disease or Disorder Yes ___ Yes ___ Pre ___ Post ___ No ___ No ___ If Yes, please specify disorder: Yes ___ Yes ___ Obesity Pre ___ Post ___ No ___ No ___ Pelvic Trauma Yes ___ Yes ___ Pre ___ Post ___ No ___ No ___
Cystocele Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Diabetes Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Diverticulitis Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Dyspareunia Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Enterocele Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Fistulas Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Hernias Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Hypertension or High Blood Pressure Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Hypotension or Low Blood Pressure Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Immune System Disease or Dysfunction including HIV/AIDS If Yes, please specify condition: Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Malnutrition Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Muscle or Disorder If Yes, please specify disorder: Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Neuromuscular Disease or Disorder If Yes, please specify disorder: Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Obesity Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Pelvic Trauma Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___
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