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Do I Need A Pelvic Floor Physical Therapist?

Once completed, Dr. Kaylee will reach out to go over your results.

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Question 1 of 13

What is your name?

Question 2 of 13

What is your email address?

Question 3 of 13

Have you ever been pregnant or are you currently pregnant?

A

Yes

B

No

Question 4 of 13

Did you have any tearing during giving birth? 

A

Yes

B

No

C

I never gave birth

Question 5 of 13

Do you have pelvic pain (in you genitals, pubic region, tailbone, or with urination or bowel movement) that exceeds a 3 on a scale of 1-10?

A

yes

B

no

Question 6 of 13

Do you have pain with sex? 

A

Yes

B

No

C

Sometimes

Question 7 of 13

Do you pee more than 10 times per day?

A

Yes

B

No

Question 8 of 13

Do you pee more than 2 times at night?

A

Yes

B

No

Question 9 of 13

Have you experience any of the following:
Check all that apply:

(Select all that apply)
A

Accidental leakage of urine with laughing, sneezing, coughing, running, or jumping

B

Accidental leakage of urine with a strong and uncontrollable urge- cannot get to the bathroom quick enough

C

Feeling you cannot empty your bladder fully

D

Must go to the bathroom only a few minutes after peeing the first time

E

Pain with urination

F

Difficulty starting to pee

G

Frequent starting and stopping of the pee when peeing

H

None of the above

Question 10 of 13

Have you noticed a separation of your stomach muscles? Bulging with certain exercises?

A

Yes

B

No

C

I think so, but not always

Question 11 of 13

Are you doing kegels properly? (yes, this is a trick question)

A

Yes, of course.

B

I think so but now I'm not so sure...

C

Never really tried them.

Question 12 of 13

Have you ever had a fall or an injury to your tailbone, low back, or sacrum? It does count if it happened when you were a child.

A

Yes

B

No

Question 13 of 13

Do you increased pressure in your pelvic region, vagina, rectum, or lower abdomen (stomach)? 

This goes hand in hand with feeling as if your vagina or your insides are falling out.

A

Yes

B

No

C

Only with certain movements or exercise

Confirm and Submit