☐ 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 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 a night.

☐ I sometimes have a feeling of increased pelvic pressure or the sensation of my pelvic organs
slipping down or falling out.

☐ I have history or pain in my low back, hip, groin, or tailbone or have sciatica.

☐ I sometimes experience one or more of the following bowel symptoms:

            ☐ Loss of bowel control.

            ☐ Feeling unable to completely empty my bowel movements.

            ☐ 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.