First NameLast NameEmail Address *PhoneWhen did the Pain Start? *YearSelect Year212621252124212321222121212021192118211721162115211421132112211121102109210821072106210521042103210221012100209920982097209620952094209320922091209020892088208720862085208420832082208120802079207820772076207520742073207220712070206920682067206620652064206320622061206020592058205720562055205420532052205120502049204820472046204520442043204220412040203920382037203620352034203320322031203020292028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926MonthSelect month123456789101112DaySelect day12345678910111213141516171819202122232425262728293031Event that started painEvent that started pain *AccidentChildbirthSport activitySexual activitySurgical procedureOnset of menstrual periodsNo event – slow onset over timeAccidentAccident Date *ChildbirthChild Birth DateChildbirth *Pain started during pregnancyPain started after vaginal deliveryPain started after cesarean sectionIII/IV degree lacerationSport activitySports ActivityWeightliftingCyclingWorking outSkiing/snowboardingRunningFootball/basketball/soccer/volleyball/baseball/hockeyMartial artsCheerleadingDancingOtherSexual activitySexual activityMasturbationUse of sexual toysOtherSurgical procedureWithout mesh *Hysterectomy (abdominal/vaginal/laparoscopic/robotic)Resection of endometriosisOophorectomyCesarean sectionProcedure for incontinence without meshProcedure for prolapse without meshHernia repair (inguinal/umbilical/incisional/other)Other major abdominal surgeryBack surgeryWith mesh *Sling for incontinenceMesh for prolapseOnset of menstrual periodsAgeVerbally Describe The EventLocation of symptomsLower backButtocksLower abdomenClitorisVulvaVaginaPerineumRectumFront of the legBack of the legMedial side of the legSymptoms Pain Types *PainNumbnessBurningItchingHypersensitivityPain LocationRightLeftBothHave you ever seen a pelvic floor physical therapistYesNoGive us more detailsHow long in months have you been seeing the therapistWere you told you have pelvic floor muscle spasm/tightnessYesNoSend MessageSave as DraftPlease do not fill in this field.
