Chiari Tethered Cord Syndrome Questionnaire

All fields with an asterisk (*) are required.

Thank You

The form was submitted successfully.

2022-CONT-Medical Center of Aurora-Chiari Tethered Cord Syndrome Questionnaire-PHI
Name*
Date/Time*
Do you have urinary urgency?
Do you urinate often during the hours that you are awake?
Do you have urinary incontinence?
Do you urinate at night?
Do you have problems starting the urinary stream?
Do you have constipation?
Do you have diarrhea?
Do you have occasional incontinence for stools?
Do you have decreased interest in sexual relations?
Do you have difficulty reaching an orgasm?
Do you have decreased sensation in your pelvic area?
Do you have low back pain?
Do you have leg pain?
Do you have numbness under the soles of your feet?
Do you keep your knees bent at night?
Do you have low back pain, leg pain, or urinary symptoms while walking up stairs?
Do you have a history of severe growing pains during childhood and adolescence?
Do you have difficulty standing longer than 60 minutes?
Do your symptoms worsen with driving or riding?
Are your symptoms worse on bumpy roads?
Have you had an injury to your spine?
Have you been told you have curvature of the spine (scoliosis)?
Have you been told you have spina bifida?