Not Sure You're In Need of Pelvic Floor Therapy?

Take this brief quiz and find out if you could benefit from working with us.

Pelvic Floor Health Quiz

Instructions: Check All That Apply

First name

Last name

Phone

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 pain being the worst pain imaginable

Yes

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

Yes

I sometimes experience one or more of the following urinary symptoms: Accidental loss of urine, Feelig unable to completely empty my bladder, Having to void within a few minutes ofa previous void, Pain or burning with urination, Difficulty starting or frequent stopping/starting of urine stream.

Yes

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

Yes

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

Yes

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

Yes

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.

Yes

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

Yes

Sexual Activity increases one or more of my other symptoms.

Yes

Prolonged sitting increases my symptoms.

Yes

This Quiz is adapted from the Cozean Pelvic Dysfunction Screening Protocol.

By submitting this quiz, I consent to receiving emails from West Pelvic Wellness.

Thanks for submitting! You will receive an email with your results.

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