Is Pelvic Floor Physical Therapy Right for You?

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Are you trying to determine if you need:
A. personal pelvic floor rehabilitation or
B. semi-private group training

Take this short quiz to figure out which program is best for you!

Based off of your answers, we will contact you to determine if you would benefit from either our personal pelvic floor rehabilitation or our semi-private group classes.

*The following is modified from the Cozean Pelvic Dysfunction Screening Protocol*

Email *

Have you ever been pregnant, are you pregnant or are you planning to become pregnant? *

Yes

Did you have any tearing during giving birth? *

Yes

I never gave birth

Do you ever have pelvic pain (in genitals, perineum, pubic or bladder area, or with urination) that exceeds a "3" from a 1-10 scale? *

Yes

Do you have pain with sex or after sex? *

Yes

Sometimes

Do you urinate more than 2 times a night? *

Yes

Some nights but not all nights

Have you experienced any of the following? *

Accidental leakage of urine with laughing, coughing or sneezing

Accidental leakage of urine with strong and uncontrollable urge

Feeling you cannot fully empty your bladder

Must use the restroom several seconds after standing from using the restroom

Pain or burning with urination

Difficulty starting a stream of urine

Frequent stopping/starting of urine stream

None of the above

Required

Have you noticed a separation of your stomach muscles? Or, have you noticed a bulging in your stomach? *

Yes

I do not know

Do you know how to do a proper kegel? *

Yes

Maybe

Have you ever had any falls onto your tailbone, low back, or buttocks region? This could be recently or even as a child! *

Yes

Do you have a history of any of the following orthopedic conditions: *

Low back pain

Sciatica

Hip pain

Groin strain

Tailbone pain

Pubic bone pain

Sacroiliac joint pain / problems

None of the above

Required

Do you have an increased sensation of pressure in your pelvic region, or feel as if your insides are falling out of your vagina or rectum? *

Yes

Provide us a brief summary of what your goals with our services. *

Name *

Phone Number *

A copy of your responses will be emailed to the address you provided.

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