Cozean Pelvic Dysfunction Screening Protocol
Please check all symptoms that apply to you. Three or more positive responses indicates that pelvic floor dysfunction is likely and that scheduling an evaluation would be warranted.
First Name
Last Name
Email
example@example.com
Select any statements below that apply to you:
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 a night.
I sometimes have a feeling of increased pelvic pressure or the sensation of my pelvic organs slipping down or falling out.
I have history or pain in my low back, hip, groin, or tailbone or have sciatica.
I sometimes experience one or more of the following bowel symptoms: loss of bowel control; feeling unable to completely empty my bowel movements; 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.
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