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Pelvic Health Assessment
Cozean Pelvic Dysfunction Screening Protocol
Instructions: Check all that apply.
First name
Last name
Email address
1. 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.
Yes
No
2. I can remember falling onto my tailbone, lower back, or buttocks (even in childhood).
Yes
No
3. I have experienced any 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
Yes
No
4. I often or occasionally have to get up to urinate two or more times at night.
Yes
No
5. I sometimes have a feeling of increased pelvic pressure or the sensation of my pelvic organs slipping down or falling out.
Yes
No
6. I have a history of pain in my low back, hip, groin, or tailbone, or have had sciatica.
Yes
No
7. 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
Yes
No
8. I sometimes experience pain or discomfort with sexual activity or intercourse.
Yes
No
9. Sexual activity increases one or more of my other symptoms.
Yes
No
10. Prolonged sitting increases my symptoms.
Yes
No
Submit
If you checked 3 or more, You might have a pelvic floor condition that could benefit from expert evaluation and treatment.
Contact us today to schedule a consultation!
