Pelvic Dysfunction Questionnaire

If you're concerned that you may have pelvic dysfunction, please take the time to fill out our questionnaire to the best of your knowledge. Feel free to add additional comments or questions in the comments section.

A therapist will contact you in the next 2 business days to discuss any questions you may have and if you may benefit from physical therapy.

Urinary Incontinence:

Do you urinate more than seven times per day?
Yes No Don't Know

Do you awake more than 2 times per night to urinate?
Yes No Don't Know

Do you experience unintentional loss of urine with a cough, sneeze, lift, or jump?
Yes No Don't Know

Do you have unintentional loss of urine at night?
Yes No Don't Know

Do you have burning or pain with urination?
Yes No Don't Know

Do you have difficulty starting the stream of urine?
Yes No Don't Know

Do you feel unable to fully empty your bladder?
Yes No Don't Know

Do you have a strong urge to urinate?
Yes No Don't Know

Constipation/Fecal Incontinence:

Do you feel unable to fully empty your bowels?
Yes No Don't Know

Do you leak or stain feces on your clothes?
Yes No Don't Know

Do you have diarrhea frequently?
Yes No Don't Know

Do you take laxatives or use enemas regularly?
Yes No Don't Know

Do you leak gas by accident?
Yes No Don't Know

Do you have pain with a bowel movement?
Yes No Don't Know

Do you have a very strong urge to move your bowels?
Yes No Don't Know

Pelvic Pain:

Do you have pain in your lower back that increases with sitting?
Yes No Don't Know

Do you have pain with penetration or an attempt at penetration? (ie. sexual intercourse, tampon use, or pelvic exams)
Yes No Don't Know

Do you have pain with a full bladder?
Yes No Don't Know

Do you have frequent urinary tract infections?
Yes No Don't Know

Do you have a history of abdominal or pelvic surgeries?
Yes No Don't Know

Did you have difficult labor that caused tearing?
Yes No Don't Know

Did you have an episiotomy?
Yes No Don't Know

Do you have pain or tension at abdominal or pelvic scars (if applicable)?
Yes No Don't Know

Comments and Questions:

Contact (All fields required):

First Name:

Last Name:

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