Does my pelvic floor need some TLC?

Name *

First Name

Last Name

Pelvic Pain

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

Falls

I can remember falling onto my tailbone, lower back, or buttocks (even inchildhood)

Urinary Symptoms

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 the stream of urine

Yes

Nighttime urination

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

Pelvic Pressure

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

Back/Hip/Groin Pain

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

Bowel

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

Sexual Pain

I sometimes experience pain or discomfort with sexual activity or intercourse

Sexual activity increases one or more of my other symptoms

Pain with Sitting

Prolonged sitting increases my symptoms