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 CIRCLES, PELVIC FLOOR DYSFUNCTION IS LIKELY. YOU MAY BENEFIT FROM AN ASSESSMENT FROM A PELVIC FLOOR REHABILITATION (PT/OT) PROVIDER.

Cozean Pelvic Dysfunction Screening Protocol