Welcome to Williamstown Physical Therapy Pelvic and Women’s Health Program. In order to help us better serve you could you please fill out the following questions prior to your evaluation and then complete the pelvic floor quiz powered by our partner company My Core Floor using the link below. This quiz will give you a score that will help us to track your progress and improvement as you move through physical therapy with us. At the end of each section there is a space for additional comments if there is anything more specific you would like your therapist to know.


What are the symptoms you hope to be addressed with pelvic floor PT?
Click all the apply.
How long have you been dealing with these symptoms?


Do you have any joint pain, back pain, or other orthopedic type symptoms that you deal with on a regular basis? Click all that apply.
Have you had any surgeries - related or unrelated to the problems you are coming for today?


Have you been pregnant and/or delivered a child in the last 12 months?
Have you been pregnant and/or delivered a child more than 12 months ago?


Do you ever leak urine with coughing, laughing, sneezing, squatting or with exercise?
Do you ever leak urine trying to get to the bathroom?
If you suffer with incontinence do you wear a pad or special underwear?
If you suffer with incontinence do you ever have to change your clothes because of leaking/accidents?
Do you have a strong sense of urgency when you have to urinate?
Do you go to the bathroom more often than every 3 hours?
Do you get up more than 1x per night to go to the bathroom?
Do you have difficulty holding back gas?
Do you ever feel you may “leak” stool or have difficulty making it to the bathroom for a bowel movement?


Have you ever been diagnosed with a vaginal prolapse, experienced vaginal pressure or have had a feeling the something is "falling out" of your vaginal opening?


Do you have general pelvic type pain (including vaginal pain, abdominal pain, hip/groin pain) during the day related to specific activities you do or clothes you wear?
Do you have pain with intercourse or avoid intercourse for fear of pain?
Is your quality of life impacted by urinary or pelvic pain issues?
Do you have pain with using a tampon, or with GYN exams?


Do you sit for more than 50% of your day?
Do you exercise 3 or more days/week?

Thank You,
Brittney and Cori