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Pelvic Floor
Pelvic Floor Questionnaire
It is strongly recommended that this questionnaire be completed prior to participation in any Peg Family Fitness class. 

** If you require assistance in completing this form please contact Peg Family Fitness. Steph will be happy to help you! **

Cozean Pelvic Floor Dysfunction Screen

Pelvic floor dysfunction is very common but often goes undiagnosed! It is estimated that 1 in 3 or 1 in 4 women are leaking urine. Pregnancy puts a lot of stress on your pelvic floor and childbirth and obstetrical trauma are two of many risk factors for pelvic floor dysfunction. 

Below are 10 questions. Please read each question and answer 'yes' or 'no'. If you answer 'yes' to 3 or more questions then pelvic floor dysfunction is likely and Steph (owner/instructor) would like to discuss this with you prior to your first class. Protecting and healing your pelvic floor are priorities for Peg Family Fitness!

We understand that pelvic floor dysfunction and its symptoms are personal and sensitive topics. You can choose how much information you share with Steph and the other Peg Family Fitness instructors and we guarantee that your personal information will be kept confidential. 


1)  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.


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

3)  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

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

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

6)  I have a history of pain in my lower back, hip, groin, or tailbone or have had sciatica?

7)  I sometimes experience one or more if 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

8)  I sometimes experience pain or discomfort with sexual activity or intercourse


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

10)  Prolonged sitting increases one or more of my other symptoms.

Did you answer 'yes' to 3 or more of the above questions?

Thank you for completing this pelvic floor screen! If you answered 'yes' to 3 or more questions keep your eyes out for an email from Steph!

Thanks for submitting!

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