Cozean Pelvic Dysfunction Screening Protocol


Instructions: Check all that apply


  • 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 urinate within a few minutes of a previous void (urination)

    • 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


If you checked 3 or more circles pelvic floor dysfunction is likely and you should contact the office and speak to Dr. Carri to find out more about how pelvic floor physical therapy can help you.