PELVIC DYSFUNCTION SCREENING
Please choose your answer for the following questions. If you selected YES for 3 or more answers, Pelvic Floor Dysfunction is Likely!
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Full Name *
Phone Number *
Email Address *
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. *
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, 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 or urine stream. *
1 point
I often or occasionally have to get up to urinate two or more times at night. *
1 point
I sometimes have a 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 unable to completely empty my 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
Sexual activity increases one or more of my other symptoms. *
1 point
Prolonged sitting increases my symptoms. *
1 point
Prolonged sitting increases my symptoms. *
1 point
What specific questions or concerns you would like to talk with a Pelvic Physical Therapist about?
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