Pelvic Health

Name *

First Name

Last Name

Phone *

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I sometimes have pelvic pain (in genitals, perineum, pubic or bladder area, or pain with urination) that exceeds a "3" on a 1 to 10 pain scale, with 10 being the worst pain imaginable. *

Yes

No

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

Yes

No

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 previous void, pain or burning with urination, difficulty starting or frequent stopping/starting urine stream. *

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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 bowel movement, difficulty initiating a bowel movement. *

Yes

No

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

Yes

No

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

Yes

No

Prolonged sitting increases my symptoms. *

Yes

No