Pelvic Health Survey
Answering YES to 3 or more questions indicates a high likelihood of pelvic floor dysfunction.
1. 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.
2. I can remember falling onto my tailbone, lower back, or buttocks (even in childhood).
3. 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
4. I often or occasionally have to get up to urinate two or more times at night.
5. I sometimes have a feeling of increased pelvic pressure or the sensation of my pelvic organs slipping down or falling out.
6. I have a history of pain in my low back, hip, groin, or tailbone or have had sciatica.
7. 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
8. I sometimes experience pain or discomfort with sexual activity or intercourse.
9. Sexual activity increases one or more of my other symptoms.
10. Prolonged sitting increases my symptoms.