MiBella - Vaginal Restoration Consult Form
ICIQ-UI Form
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Sex
Female
Male
How often do you leak urine?
0 - Never
1 - About once a week or less
2 - 2 or 3 times a week
3 - About once a day
4 - Several times a day
5 - All the time
How much urine do you think you usually leak (whether you wear protection or not)?
0 - None
2 - A small amount
4 - A moderate amount
6 - A large amount
Overall, how much does leaking urine interfere with your everyday life?
0 (Not at all)
1
2
3
4
5
6
7
8
9 (A great deal)
When does urine leak? (Please check all that apply to you)
Never - Urine does not leak
Leaks before you can get to the bathroom
Leaks when you cough or sneeze
Leaks when you are asleep
Leaks when you are physically active/exercising
Leaks when you have finished urinating and are dressed
Leaks for no obvious reason
Leaks all the time
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FSFI Scoring Appendix
Over the past 4 weeks, how often did you feel sexual desire or interest?
1 - Almost never or never
2 - A few times (less than half the time)
3 - Sometimes (about half the time)
4 - Most times (more than half the time)
5 - Almost always or always
Over the past 4 weeks, how would you rate your level (degree) of sexual desire or interest?
1 - Very low or none at all
2 - Low
3 - Moderate
4 - High
5 - Very high
Over the past 4 weeks, how often did you feel sexually aroused ("turned on") during sexual activity or intercourse?
0 - No sexual activity
1 - Almost never or never
2 - A few times (less than half the time)
3 - Sometimes (about half the time)
4 - Most times (more than half the time)
5 - Almost always or always
Over the past 4 weeks, would you rate your level of sexual arousal ("turn on") during sexual activity or intercourse?
0 - No sexual activity
1 - Very low or none at all
2 - Low
3 - Moderate
4 - High
5 - Very high
Over the past 4 weeks, how often have you been satisfied with your arousal (excitement) during sexual activity or intercourse?
0 - No sexual activity
1 - Almost never or never
2 - A few times (less than half the time)
3 - Sometimes (about half the time)
4 - Most times (more than half the time)
5 - Almost always or always
Over the past 4 weeks, how often did you become lubricated ("wet") during sexual activity or intercourse?
0 - No sexual activity
1 - Almost never or never
2 - A few times (less than half the time)
3 - Sometimes (about half the time)
4 - Most times (more than half the time)
5 - Almost always or always
Over the past 4 weeks, how difficult was it to become lubricated ("wet") during sexual activity or intercourse?
0 - No sexual activity
1 - Extremely difficult or impossible
2 - Very difficult
3 - Difficult
4 - Slightly difficult
5 - Not difficult
Over the past 4 weeks, how often did you maintain your lubrication ("wetness") until completion of sexual activity or intercourse?
0 - No sexual activity
1 - Almost never or never
2 - A few times (less than half the time)
3 - Sometimes (about half the time)
4 - Most times (more than half the time)
5 - Almost always or always
Over the past 4 weeks, how difficult was it to maintain your lubrication ("wetness") until completion of sexual activity or intercourse?
0 - No sexual activity
1 - Extremely difficult or impossible
2 - Very difficult
3 - Difficult
4 - Slightly difficult
5 - Not difficult
Over the past 4 weeks, when you had sexual stimulation or intercourse, how often did you reach orgasm (climax)?
0 - No sexual activity
1 - Almost never or never
2 - A few times (less than half the time)
3 - Sometimes (about half the time)
4 - Most times (more than half the time)
5 - Almost always or always
Over the past 4 weeks, when you had sexual stimulation or intercourse, how difficult was it for you to reach orgasm (climax)?
0 - No sexual activity
1 - Extremely difficult or impossible
2 - Very difficult
3 - Difficult
4 - Slightly difficult
5 - Not difficult
Over the past 4 weeks, how satisfied were you with your ability to reach orgasm (climax) during sexual activity or intercourse?
0 - No sexual activity
1 - Very dissatisfied
2 - Moderately dissatisfied
3 - About equally satisfied and dissatisfied
4 - Moderately satisfied
5 - Very satisfied
Over the past 4 weeks, how satisfied have you been with the amount of emotional closeness during sexual activity between you and your partner?
0 - No sexual activity
1 - Very dissatisfied
2 - Moderately dissatisfied
3 - About equally satisfied and dissatisfied
4 - Moderately satisfied
5 - Very satisfied
Over the past 4 weeks, how satisfied have you been with your sexual relationship with your partner?
0 - No sexual activity
1 - Very dissatisfied
2 - Moderately dissatisfied
3 - About equally satisfied and dissatisfied
4 - Moderately satisfied
5 - Very satisfied
Over the past 4 weeks, how satisfied have you been with your overall sexual life?
0 - No sexual activity
1 - Very dissatisfied
2 - Moderately dissatisfied
3 - About equally satisfied and dissatisfied
4 - Moderately satisfied
5 - Very satisfied
Over the past 4 weeks, how often did you experience discomfort or pain during vaginal penetration?
0 - Did not attempt intercourse
1 - Almost always or always
2 - A few times (less than half the time)
3 - Sometimes (about half the time)
4 - Most times (more than half the time)
5 - Almost never or never
Over the past 4 weeks, how often did you experience discomfort or pain following vaginal penetration?
0 - Did not attempt intercourse
1 - Almost always or always
2 - A few times (less than half the time)
3 - Sometimes (about half the time)
4 - Most times (more than half the time)
5 - Almost never or never
Over the past 4 weeks, how would you rate your level (degree) of discomfort or pain during or following vaginal penetration?
0 - Did not attempt intercourse
1 - Very high
2 - High
3 - Moderate
4 - Low
5 - Very low or none at all
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Vaginal Laxity Questionnaire
Instructions: Please rate your overall perception of vaginal laxity or looseness during intercourse by checking only one item below.
How would you rate your current level of vaginal laxity/looseness during intercourse?
1 - Very loose
2 - Moderately loose
3 - Slightly loose
4 - Neither loose nor tight
5 - Slightly tight
6 - Moderately tight
7 - Very tight
Submit
Should be Empty: