Pelvic Health Questionnaire

Please check all that apply to you

Name *

First

Last

Email *

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 10 being the worst pain imaginable. *YesNo

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

I sometimes experience one or more of the following urinary symptoms: *

• Accidental loss of urine
• Feeling unable to empty bladder
• Having to void within a few minutes of previous void
• Pain or burning during urination
• Difficulty starting or frequent stop/starting of urine stream
• None of these apply

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

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

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

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 bowel movement
• Difficulty initiating a bowel movement
• None of these apply

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

Sexual activity increases one or more of my symptoms. *YesNo

Prolonged sitting increases my symptoms. *YesNo

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