Cozean Pelvic Dysfunction Screening Protocol Instructions
If you tick three of more boxes pelvic floor dysfunction is likely:
1. I sometimes have pelvic pain (in genitals, peri neum, pubic, or bladder area, or pain
with urination) that exceeds a ‘3’ on a 1 10 pain scale with 10 being the worst pain
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 a 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 history or pain in my low back, hip, groin, or tailbone or have sciatica.
7. I sometimes experience one or more of the following bowel symptoms:
- Loss of bowel control
- Feeling unable to completely empty my bowel movements
- 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.