First NameLast NameEmail Address *PhoneWhen did the Pain Start? *YearSelect Year212421232122212121202119211821172116211521142113211221112110210921082107210621052104210321022101210020992098209720962095209420932092209120902089208820872086208520842083208220812080207920782077207620752074207320722071207020692068206720662065206420632062206120602059205820572056205520542053205220512050204920482047204620452044204320422041204020392038203720362035203420332032203120302029202820272026202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924MonthSelect 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.
