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INSTRUCTIONS: CHECK ALL THAT APPLY
- 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
- I can remember falling onto my tailbone, lower back, or buttocks (even in childhood)
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
- I often or occasionally have to get up to urinate two or more times at night
- I sometimes have a feeling of increased pelvic pressure or the sensation of my pelvic organs slipping down or falling out
- I have a history of pain in my low back, hip, groin, or tailbone or have had sciatica
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
- I sometimes experience pain or discomfort with sexual activity or intercourse
- Sexual activity increases one or more of my other symptoms
- Prolonged sitting increases my symptoms
IF YOU CHECKED 3 OR MORE, PELVIC FLOOR DYSFUNCTION IS LIKELY. YOU MAY BENEFIT FROM AN ASSESSMENT FROM A PELVIC FLOOR PHYSICAL THERAPIST.

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