Pelvic Health Screening Tool

Please answer the following questions:

  1. Do you experience at least one of the following bladder symptoms? YES/NO
    • Leaking with coughing, sneezing, jumping, running, or weightlifting
    • Leaking with a strong sense of urgency, such as seeing the toilet or hearing running water
    • Need for bathroom breaks more than every 3 hours
    • Feeling that you are unable to completely empty your bladder
    • Increase or delay in time to start the flow of urine
    • Waking up 1 or more times during the night to urinate
  2. Do you experience at least one of the following bowel symptoms? YES/NO
    • Chronic constipation or diarrhea
    • Smearing of fecal matter on underwear or fecal leakage
    • Regularly straining with bowel movements
    • Feeling that you are unable to completely void
    • Chronic anal fissures or hemorrhoids
  3. Do you experience at least one of the following pain symptoms? YES/NO
    • Pain or burning with urination
    • Bladder pain related to diet
    • Pain with defecation or straining
    • Chronic abdominal pain or distention associated with constipation
    • Pain during or after sexual activity of any kind
    • Chronic low back, abdominal, hip, groin pain, or sciatica
    • Pelvic pain with exercise, cardio, weightlifting
    • Pelvic pain when sitting for long periods of time
  4. Do you have a history of pelvic trauma, including a tailbone injury? YES/NO
  5. Do you experience symptoms of pelvic heaviness or pressure? YES/NO
  6. Do you have a history of abdominal or genital surgeries? YES/NO
  7. Do you have a history of 1 or more pregnancies with either vaginal or cesarean delivery? YES/NO
  8. Are you preparing for labor and delivery? YES/NO
  9. Do you suffer from a reproductive disorder like endometriosis or PCOS? YES/NO

If you answered “Yes” to 2 or more questions, you may benefit from Pelvic Health Physical Therapy to address any possible pelvic floor dysfunction present. Your treating clinician can help treat or manage these symptoms and guide a referral to the appropriate medical professional. Click here to request an appointment. Please include Pelvic Health Physical Therapy in the Reason for Appointment field.