Pelvic Health Screening Questionnaire

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This 10-question survey was shown to correctly identify more than 90% of patients with confirmed pelvic floor dysfunction. If you score a 3 or higher on this questionnaire, pelvic floor dysfunction is likely. You can always talk with a qualified pelvic floor physical therapist if you have any questions about your pelvic health.

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Screening Questionnaire

I sometimes or occasionally have pelvic pain (in genitals, perineum, pubic or bladder area, or pain with urination) that exceeds at '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 (incontinence), feeling unable to completely empty my bladder, having to void within a few minutes of a previous void, pain or burning with urination, or difficulty starting or frequent stopping/starting of urine stream (1 point) *

Yes

I sometimes or occasionally have to get up to urinate two or more times at night (1 point) *

Yes

I sometimes have the 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 of being unable to completely empty the bowels, straining or pain with a bowel movement, or difficulty initiating a bowel movement (1 point) *

Yes

I sometimes experience pain or discomfort with sexual activity or intercourse (1 point) *

Yes

I notice that sexual activity increases one or more of my other symptoms (1 point) *

Yes

Prolonged sitting increases my symptoms (1 point) *

Yes

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