Pelvic Health Questionnaire

Take the questionnaire below to find out if you have pelvic floor dysfunction and would benefit from seeing a pelvic health physical therapist!

Answer YES or NO to the following:

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
□ 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 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
□ 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 a bowel movement
□ Difficulty initiating a bowel movement

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

Your Results

If you answered YES to three or more of the above, you are likely experiencing pelvic floor dysfunction. Speak to your provider about a referral to the Memorial Pelvic Health Rehabilitation team to set up an appointment.

Appointments can be scheduled by calling Memorial Therapy & Rehabilitation at (937) 578-7841. Provider referrals can be faxed to (937) 578-7891.

*The Cozean Questionnaire was created by Nicole Cozean, PT, DPT, WCS, CSCS* and Jesse Cozean, MBA.