COZEAN PELVIC FLOOR DYSFUNCTION SCREENING QUESTIONNAIRE
This questionnaire is a simple way to determine if you would benefit from seeing a physical therapist who specializes in pelvic health.
**Answer yes or no to the following 10 questions.
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
I can remember falling onto my tailbone, lower back, or buttocks (even in childhood)
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
I often or occasionally have to get up to urinate two or more times at night
I sometimes have a feeling of increased pelvic pressure or the sensation of my pelvic organs slipping down or falling out
I have a history of pain in my low back, hip, groin, or tailbone or have had sciatica
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
I sometimes experience pain or discomfort with sexual activity or intercourse
Sexual activity increases one or more of my other symptoms
Prolonged sitting increases my symptoms
If you answered YES to 3 or more of the above, you are highly likely experiencing pelvic floor dysfunction.
As a pelvic floor physical therapist, I can evaluate you, determine conclusively whether pelvic floor dysfunction is the underlying cause of your symptoms, and get you on the path to resolving these common - but not normal! - symptoms. Request information to find out about working with Dr. Rebecca.
Feel free to print this questionnaire for reference or to take it into your doctor to discuss.
**The Cozean Questionnaire was created by Nicole Cozean, PT, DPT, WCS, CSCS and Jesse Cozean, MBA