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Vicki Sims, PT, CHT
Gainesville Physical Therapy
1296 Sims Street, Suite A
Gainesville, GA 30501
Phone: 770.297.1700
vsims@gainesvillept.com
www.gainesvillept.com

David Mesnick, PT, cMDT
Body Mechanics Physical Therapy
550 Peachtree Street, Suite 1760
Atlanta, Georgia 30308
Phone: 404.817.0734
dmesnick@bodymechanicsatl.com
www.bodymechanicsatl.com

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Self Evaluation

Please Answer the following questions Yes or No:

1. Do you have pain directly over one side of your tailbone (sacrum)?
Yes No

2. Do you have buttock pain?
Yes No

3. Do you have radiating leg pain?
Yes No

4. Do you have hip or groin pain?
Yes No

5. Do you have increased pain with stair climbing?
Yes No

6. Do you have increased pain with prolonged sitting or standing?
Yes No

7. Are you experiencing urinary frequency?
Yes No

8. Do you have increased pain with menstruation?
Yes No N/A

9. Do you have increased pain with sexual intercourse?
Yes No

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