Do I need pelvic floor therapy

Instructions: Check all that apply

O 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.

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

O 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.

O I often or occasionally have to get up to urinate two or more times a night.

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

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

O 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

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

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

O Prolonged sitting increases my symptoms.


If you checked three or more circles, pelvic floor dysfunction is likely.

Call Dr. Sunel at Trailhead Pelvic & Visceral Physical Therapy to schedule a pelvic floor evaluation.
505 357 0055

(Thanks to Nicole Cozean for developing this protocol and letting us use it freely.)