Survey
First Name
Last Name
Email
Age
18-30
31-45
46-60
>60
Occupation
I am:
Pregnant
Postpartum (<1 year)
Postpartum (>1 year)
Trying to get pregnant
Just wonderful, glorious me!
Have you experienced any of the following in the past year?
pelvic pain
urinary leakage
overactive bladder (severe urgency and frequency of urination)
pelvic pressure/vaginal bulging
core weakness
low back, hip, or SIJ pain
constipation
painful intercourse
fecal incontinence
Other
On a scale of 1-5, with 1 being not very bothered and 5 being very bothered, how bothered are you by the above issues?
On a scale of 1-5, with 1 being not very bothered and 5 being very bothered, how bothered are you by the above issues?
Have you received treatment for the above issues in the past?
Yes
No
Briefly describe the treatment received
Was treatment helpful?
Yes
No
Why not?
Would you be interested in pursuing treatment for these issues?
Yes
No
What would be most important to you abut the treatment you recive? Please check up t 3 answers:
Price/Affordability
Location/Convenience
Personalization/One-on-one attention
Education and empowerment
Privacy and safety
Emphasis on manual (hands-on) therapies
Emphasis on exercise and lifestyle instruction
What treatment model would be most appealing to you at this time?
In-home physical therapy visit
Virtual (telehealth) physical therapy visit
Physical therapy visit at an outpatient clinic
Educational workshop with handouts and general instruction
Private in-home physical therapy evaluation with small group follow-up, either in person or virtually
None of the above
Other
Please describe your ideal treatment scenario -- feel free to be as descriptive as you wish:
If you re not intrested in pursuing treatmen at this time, what barriers are currently standig in your way?
Financial
Time
Interest/Motivation
Knowledge -- I don't know enough to know if I need help
It's such a private thing -- I don't know if I'm ready
Other
Additional comments:
Submit
