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

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

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

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

5. Do you have an IUD fitted?

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

7. What is the pessary type and size?

8. My previous pessary was....

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