Pelvic Floor Dysfunction Screening

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If you have one or more of the following symptoms, it is likely that you have a pelvic floor dysfunction. If you have 3 or more symptoms, then would benefit from an evaluation by a Pelvic Health Therapist.

Email *

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 worse pain imaginable. *

Yes

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

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

*Difficult starting or frequent stopping/starting of urine stream

Yes

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

Yes

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

Yes

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

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

Yes

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

Yes

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

Yes

Prolonged siting increases my symptoms *

Yes

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

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