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1. How long has it been since your most recent visit with your healthcare provider?

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2. Name of medical professional who fitted/checked my pessary

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3. During your most recent visit, did you talk with Medical professional about any health questions or concerns?

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4. Do you now need or take medicine prescribed by a doctor?
Have you be prescribed Oestrogen cream?

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5. Do you have an IUD fitted?

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6. What type of prolapse(s) do you have?
What grade of prolapse(s) do you have?

  Grade 1-2 Grade 2-3 Grade 3-4 Don't know
Uterine
Cystocele
Rectocele
Urethrocele
Enterocele

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7. What is the pessary type and size?

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8. My previous pessary was....

T