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 streamI 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 movementI 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