Please complete prior to 1st session

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* 1. Do you feel like there is a heaviness or pressure in your vagina or rectum (other than prior to eliminating)

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* 2. Do you have jaw pain or migraines, low back pain, knee pain, foot, leg, hip pain, pelvic, buttocks, abdominal or tailbone pain that is not associated to a fall or specific injury? If yes please list all areas that you have pain. 

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* 3. Do you ever have the symptoms of a urinary tract infection, but your tests come back negative?

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* 4. Do you have tenderness or pain during intercourse or during orgasm or after intercourse?

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* 5. Have you experienced trauma from abuse or rape?

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* 6. Are you struggling with anxiety or stress?

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* 7. Do you sit for the most of your day?

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* 8. Do you exercise regularly or have a job/hobby that requires physical effort? If so, please list the types of activities. and how often you do them. 

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* 9. Have you had a hysterectomy, episiotomy, prolapse repair, surgery for endometriosis, cyst or fibroids or any other pelvic surgery. If yes please list surgeries or list issues that you are trying to address.

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* 10. Are you approaching menopause or are in menopause? If so, are you on hormone replacement therapy? Have you had your hormones tested? Please end this question by indicating your name so that I can link this part of the survey to your part 1.

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