Name *

First Name

Last Name

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

Yes

No

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

Yes

No

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

Yes

No

I often or occasionally have to get up to urinate two or more times at night

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

I sometimes experience pain or discomfort with sexual activity or intercourse

Yes

No

Sexual activity increases one or more of my other symptoms

Yes

No

Prolonged sitting increases my symptoms

Yes

No