Pelvic Dysfunction Questionnaire

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Email *

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Please check or select "yes" or "no" for all items that apply to you

I sometimes have pelvic pain (in genitals, perineum, pubic, or bladder area, or pain with urination)that exceeds a ‘3’ on a 1-10 pain scale with 10 being the worst pain imaginable. *

Yes

I can remember falling onto my tailbone, lower back, or buttocks (even in childhood) *

Yes

I sometimes experience one or more of the following urinary symptoms *

Accidental loss of urine

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

I often or occasionally have to get up to urinate two or more times at nigh *

Yes

I sometimes have a feeling of increased pelvic pressure or the sensation of my pelvic organs slipping down or falling out *

Yes

I have a history of pain in my low back, hip, groin, or tailbone or have had sciatica *

Yes

I sometimes experience one or more of the following bowel symptom *

Loss of bowel control

Feeling unable to completely empty my bowels

Straining or pain with bowel movement

Difficulty initiating bowel movement

I sometimes experience pain or discomfort with sexual activity or intercourse *

Yes

Sexual activity increases one or more of my other symptoms *

Yes

Prolonged sitting increases my symptoms *

Yes

If you checked 3 or more circles, Pelvic Floor Dysfunction is likely. You may benefit from an assessment from a Pelvic Floor Physical Therapist.

Name *

Email *

Phone Number *

Preferred method of contact *

Phone call

e-mail

Where did you hear about us? *

If a specific referral by someone, who do we have to thank? *

Congratulations. You are one step closer to find out solution for your problem

We will contact you within 24-48 hours Monday-Friday

Any information shared on this form will not be used in any other way than to contact you regarding your results. Pelvic Dysfunction Screening Protocol form from Nicole Cozean, PT, DPT, WCS and Jesse Cozean, MBA

A copy of your responses will be emailed to .

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