Please answer the following questions:
- 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
- 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
- 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
- Do you have a history of pelvic trauma, including a tailbone injury? YES/NO
- Do you experience symptoms of pelvic heaviness or pressure? YES/NO
- Do you have a history of abdominal or genital surgeries? YES/NO
- Do you have a history of 1 or more pregnancies with either vaginal or cesarean delivery? YES/NO
- Are you preparing for labor and delivery? YES/NO
- 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.