First NameLast NameEmail Address *PhoneWhen did the Pain Start? *YearSelect Year212521242123212221212120211921182117211621152114211321122111211021092108210721062105210421032102210121002099209820972096209520942093209220912090208920882087208620852084208320822081208020792078207720762075207420732072207120702069206820672066206520642063206220612060205920582057205620552054205320522051205020492048204720462045204420432042204120402039203820372036203520342033203220312030202920282027202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925MonthSelect 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.
