Pelvic Floor Therapy Questionnaire

Please correct the errors described below.

Please fill in the following questionnaire to the best of your ability. The therapist will review the answers with you at your appointment.



Do you have pain with:

Test results

Bladder symptoms

Do you lose urine when you:

Bowel symptoms

Thank you for taking the time to fill out this questionnaire.


I acknowledge and understand that I have been referred for evaluation and treatment of pelvic floor dysfunction. Pelvic floor dysfunctions include, but are not limited to, urinary or fecal incontinence; difficulty with bowel, bladder, or sexual functions; painful scars after childbirth or surgery; persistent sacroiliac or low back pain; or pelvic pain conditions.

I understand that to evaluate my condition it may be necessary, initially and periodically, to have my therapist perform an internal pelvic floor muscle examination. This examination is performed by observing and/ or palpating the perineal region including the vagina and/or rectum. This evaluation will assess skin condition, reflexes, muscle tone, length, strength and endurance, scar mobility, and function of the pelvic floor region. Such evaluation may include vaginal or rectal sensors for muscle biofeedback.

Treatment may include, but not be limited to, the following: observation, palpation, use of perineal sensors, vaginal or rectal sensors for biofeedback and/ or electrical stimulation, ultrasound, heat, cold, stretching and strengthening exercises, soft tissue and/ or joint mobilization, and educational instruction

I understand that in order for therapy to be effective, I must come as scheduled unless there are unusual circumstances that prevent me from attending therapy. I agree to cooperate with and carry out the home program assigned to me. If I have difficulty with any part of my treatment program, I will discuss it with my therapist.

  1. The purpose, risks, and benefits of this evaluation will be explained to me.
  2. I understand that I can terminate the procedure at any time.
  3. I understand that I am responsible for immediately telling the examiner if I am having any discomfort or unusual symptoms during the evaluation.
  4. I have the option of having a second person present in the room during the procedure and

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