Pelvic Floor Function Questionnaire

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This assessment is to determine if you may have pelvic floor dysfunction. Instructions:
Please check or select "yes" for ALL items that apply to your situation.

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 worst 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

Difficulty starting or frequent stopping/starting of urine stream

None of the above

Required

I often or occasionally have to get up to urinate two or more times a 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 history or pain in my low back, hip, groin, or tailbone or have sciatica. *

Yes

I sometimes experience one or more of the following bowel symptoms: *

Loss of bowel control

Feeling unable to completely empty my bowel movements

Straining or pain with a bowel movement

Difficulty initiating a bowel movement

None of the above

Required

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

Yes

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

Yes

Prolonged sitting increases my symptoms. *

Yes

Name *

Date *

YYYY

Preferred Method of Contact *

Phone

Phone Number *

Where did you find out about Phoenix PT? *

Google Search for (state below in "other")

Physician/midwife/other medical provider (state name below in "other")

Varsity House Gym or coach (please name coach below)

Fitness Instructor/Personal Trainer (state name below in "other")

Doula (state name below in "other")

Fourth Trimester Support Circle

Pure Barre Park Ridge

CS Fit Allendale

Bloom Baby Doula Network

Hudson Valley Birth Network

Other:

Required

If you would like to discuss your results with a pelvic health coach, we can reach out to you via your preferred method of contact within the next 24-48 hours Monday - Friday.

Any information shared on this form including all personal details will not be used in any other way than to contact you regarding your results. Pelvic Dysfunction Screening Protocol form by Nicole Cozean, PT, DPT, WCS, CSCS* and Jesse Cozean, MBA.

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

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