COZEAN PELVIC DYSFUNCTION Screening Tool

Instructions: Check all that apply:

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.

2. I can remember falling onto my tailbone, lower back, or buttocks (even in childhood).

3. 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.

4. I often or occasionally have to get up to urinate two or more times at night.

5. I sometimes have a feeling of increased pelvic pressure or the sensation of my pelvic organs slipping down or falling out.

6. I have a history of pain in my low back, hip, groin, or tailbone or have had sciatica.

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.

8. I sometimes experience pain or discomfort with sexual activity or intercourse.

9. Sexual activity increases one or more of my other symptoms.

10. Prolonged sitting increases my symptoms.

**IF YOU CHECKED 3 OR MORE BOXES, PELVIC FLOOR DYSFUNCTION IS LIKELY. CONSIDER TALKING TO A PELVIC HEALTH PHYSICAL THERAPIST

Warrior Physical Therapy LLC

Screening Tool Created By: Nicole Cozean, PT, DPT, WCS, CSCS