Pelvic Health Quiz

I sometimes have pelvic pain (in genitals, perineum, pubic or pain with urination) that exceeds a '3' on a 1-10 pain scale, where 10 is the worst pain imaginable.(Required)

Yes

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

Yes

I sometimes experience one or more of the following urinary symptoms.(Required)

Yes

Accidental loss of urine
Feeling unable to void within a few minutes of a previous void
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.(Required)

Yes

I sometimes have a feeling of increased pelvic pressure or the sensation of my pelvic organs slipping down or fallingout.(Required)

Yes

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

Yes

I sometimes experience one or more of the following bowel symptoms.(Required)

Yes

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.(Required)

Yes

Sexual activity increases one or more of my other symptoms.(Required)

Yes

Prolonged sitting increases my symptoms.(Required)

Yes

Comments

This field is for validation purposes and should be left unchanged.

I had lymph nodes removed as part of my breast cancer treatment(Required)

Yes

I had radiation as part of my cancer treatments(Required)

Yes

I feel pain or pulling down my arm with reaching.(Required)

Yes

I am taking a SERMs hormone therapy (i.e., Tumoxifen, Nolvadex, Evista)(Required)

Yes

I feel fullness and/or swelling in my arm, hand or breast.(Required)

Yes

I am unsure how to return to safe effective exercise regime.(Required)

Yes

I have fatigue & need guidance about how to get my energy back.(Required)

Yes

I am starting to have joint pain since starting my aromatase inhibitor medication (Femara, Arimidex).(Required)

Yes

Phone

This field is for validation purposes and should be left unchanged.

Wilmington – Oleander Dr.

Leland

Hampstead

Wilmington – Midtown/Shipyard

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Pelvic Health Quiz