1 → Do you ever have pelvic pain that exceeds a '3' on a 1-10 pain scale? (In your genitals, perineum, pubic or bladder area, or with urination) *

Yes

No

2 → Have you ever had any falls onto your tailbone, lower back, or buttocks (even childhood) that you remember? *

Yes

No

3 → Do you ever experience ANY of the following urinary symptoms? *

Yes

No

4 → Do you ever have a feeling of increased pelvic pressure or the sensation of your pelvic organs slipping out? *

Yes

No

5 → Do you have a history of ANY of the following orthopedic conditions? *

Yes

No

6 → Do you ever experience ANY of the following bowel symptoms? *

Yes

No

7 → Do you ever experience pain or discomfort with sexual activity? *

Yes

No

Are there any specific questions or concerns that you have today that you would like to share? (Optional)

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Phone *