OSW FREE QUESTIONNAIRE
COZEAN PELVIC DYSFUNCTION SCREENING PROTOCOL
Sign in to Google to save your progress. Learn more
Email *
Phone number *
First Name *
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
Clear selection
I can remember falling onto my tailbone, lower back, or buttocks (even in childhood)
Clear selection

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


Clear selection
I often or occasionally have to get up to urinate two or more times at night
Clear selection
I sometimes have a feeling of increased pelvic pressure or the sensation of my pelvic organs slipping down or falling out
Clear selection
I have a history of pain in my low back, hip, groin, or tailbone or have had sciatica
Clear selection

I sometimes experience one or more of the following bowel symptoms: 

Loss of bowel control 

Feeling unable to completely empty my bowels 

Straining or pain with a bowel movement 

Difficulty initiating a bowel movement


Clear selection
I sometimes experience pain or discomfort with sexual activity or intercourse
Clear selection
Sexual activity increases one or more of my other symptoms
Clear selection
Prolonged sitting increases my symptoms
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of One Strong Woman Therapy, LLC..

Does this form look suspicious? Report

Google Forms