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Cozean Pelvic Dysfunction Screening Protocol
This 10-question survey was shown to correctly identify more than 90% of patients with confirmed pelvic floor dysfunction.  Fill out the below questionnaire to see if you may have pelvic floor dysfunction.

Used with permission from: pelvicsanity.com
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Email *
Name *
Screening Questionnaire
I sometimes or occasionally have pelvic pain (in genitals, perineum, pubic or bladder area, or pain with urination) that exceeds at '3' on a 1-10 pain scale, with 10 being the worst pain imaginable *
1 point
I can remember falling onto my tailbone, lower back, or buttocks (even in childhood) *
1 point
I sometimes experience one (or more) of the following urinary symptoms: 
-accidental loss of urine (incontinence)
-feeling unable to completely empty my bladder
-having to void within a few minutes of a previous void
-pain or burning with urination
-difficulty starting or frequent stopping/starting of urine stream
 *
1 point
I sometimes or occasionally have to get up to urinate two or more times at night *
1 point
I sometimes have the feeling of increased pelvic pressure or the sensation of my pelvic organs slipping down or falling out *
1 point
I have a history of pain in my low back, hip, groin or tailbone, or have had sciatica *
1 point
I sometimes experience one (or more) of the following bowel symptoms: 
-loss of bowel control
-feeling of being unable to completely empty the bowels
-straining or pain with a bowel movement
-difficulty initiating a bowel movement
 *
1 point
I sometimes experience pain or discomfort with sexual activity or intercourse *
1 point
I notice that sexual activity increases one or more of my other symptoms *
1 point
Prolonged sitting increases my symptoms *
1 point
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