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? *

Central Phoenix

Casa Grande

I am in AZ but I don't know which clinic I'm closest to.

I am not in Arizona but would consider traveling there for treatment.

I am not in Arizona and have no desire to travel there for treatment.

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

Yes

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

1 point

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. *

1 point

Yes

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

1 point

Yes

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

1 point

Yes

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

1 point

Yes

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

Yes

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

1 point

Yes

Sexual activity increases one or more of my other symptoms. *

1 point

Yes

Prolonged sitting increases my. symptoms *

1 point

Yes

Never submit passwords through Google Forms.

This form was created inside of The Pelvic Docs. Report Abuse

Forms