Free Online Pelvic Floor Dysfunction Screening Protocol
Email address *
1-in-4 women suffer from pelvic floor pain or dysfunction. This questionnaire has been shown in the research to be able to correctly identify 91% of the women in whom a musculoskeletal condition may be causing their pelvic floor pain or dysfunction. The great thing is that most musculoskeletal conditions are treatable!
What is your first name? *
Your answer
What is your last name? *
Your answer
Phone Number *
Your answer
Which clinic are you located closest to? *
Please answer the following 10 questions with either a yes or no answer.
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 of 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
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