Patient Questionnaires

Bowel, Bladder or Pelvic Symptoms

These two questionnaires will ask you if you have certain bowel, bladder, or pelvic symptoms and, if you do, how much they bother you. Please fill out both tests if you have abdominal, vulvar, pelvic and/or rectal pain with intercourse, with use of a tampon, with getting a pelvic exam at your gynecologist’s office; with urinating or having a bowel movement or with sitting.

Impact to Activities, Relationships and Feelings

Some women find that bladder, bowel, or vaginal symptoms affect their activities, relationships, and feelings. For each question place an “X” in the response that best describes how much your activities, relationships, or feelings have been affected by your bladder, bowel, or vaginal symptoms or conditions over the last 3 months.

Low Back, Sacral or Coccyx Pain

Marci helped me through pregnancy and post-pregnancy with her specialized physical therapy. Without her customized blend of massage and treatment I would have had a very painful pregnancy. With her help I was able to complete a triathlon just 6 months after delivering my baby. I would recommend her …

Stacy S.