1️⃣ When you cough, sneeze, or laugh, do you ever leak urine?
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Never
Occasionally
Often
2️⃣ Do you leak when you jump, run, or lift weights?
Nope
Sometimes
Yes, and it's frustrating
3️⃣ Do you ever feel heaviness, pressure, or bulging in your pelvic area?
Never
Occasionally
Often, especially at the end of the day or after exercise
4️⃣ Do you feel like you need to pee all the time or can’t fully empty your bladder?
No
Sometimes
Yes, frequently
5️⃣ Have you had any pregnancies or deliveries (vaginal or C-section)?
No
Yes, one
Yes, multiple
6️⃣ Do you experience pain with intimacy, tampons, or pelvic exams?
Never
Sometimes
Often
7️⃣ Do you feel weak or disconnected through your core or hips during workouts?
No
Occasionally
Yes, often
8️⃣ How confident do you feel doing activities like jumping, running, or lifting heavy weights without leaking?
Totally confident
Somewhat confident
Not confident at all
Full Name
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Phone
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Email
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