Email* example@example.com
1 → Do you ever have pelvic pain that exceeds a '3' on a 1-10 pain scale?* Please Select Yes No (In your genitals, perineum, pubic or bladder area, or with urination)
2 → Have you ever had any falls onto your tailbone, lower back, or buttocks (even childhood) that you remember?* Please Select Yes No
3 → Do you ever experience ANY of the following urinary symptoms?* Please Select Yes No • Accidental loss of urine with coughing, laughing, sneezing, or exercising • Accidental loss of urine with strong, uncontrollable urge • Feeling that you cannot completely empty your bladder
4 → Do you ever have a feeling of increased pelvic pressure or the sensation of your pelvic organs slipping out? Please Select Yes No
5 → Do you ever have a feeling of increased pelvic pressure or the sensation of your pelvic organs slipping out?* Please Select Yes No • Accidental loss of urine with coughing, laughing, sneezing, or exercising• Accidental loss of urine with strong, uncontrollable urge• Feeling that you cannot completely empty your bladder
6 → Do you have a history of ANY of the following orthopedic conditions?* Please Select Yes No • Low back pain • Sciatica • Hip pain • Groin strain • Tailbone pain
7 → Do you ever experience ANY of the following bowel symptoms?* Please Select Yes No • Loss of bowel control when coughing, sneezing, or laughing• Loss of bowel control with strong uncontrollable urge• Feeling that you cannot completely empty your bowels• Experiencing increased pain with bowel movements• Frequently having to strain to have a bowel movement• Have difficulty initiating a bowel movement
8 → Do you ever experience pain or discomfort with sexual activity?* Please Select Yes No
9 → Does prolonged sitting increase your symptoms?* Please Select Yes No
Are there any specific questions or concerns that you have today that you would like to share?*
Would you like a personal call regarding the results of your quiz? If so, leave your number below.
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