Cozean Pelvic Dysfunction Screening Tool

Check all that apply.

• 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 (pee) within a few minutes of a previous void (pee).

  • 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 checked 3 or more, pelvic floor dysfunction is likely and seeing a pelvic health therapist would be a great option for you!