COZEAN PELVIC DYSFUNCTION
SCREENING PROTOCOL

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Are you pregnant?

Are you recently postpartum? (1 year or less)

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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 within a few minutes of a previous void

• 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

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