Menu
Skip to left header navigation
Skip to right header navigation
Skip to main content
Skip to secondary navigation

Before Header

Praise
Contact
Log In

VIP Online Training Programs for Professionals and Patients

Get 1:1 Help
Join the Women’s Club
About

Media
Programs for Women
Professionals
Blog

Mobile Menu

Praise
Contact
Log In

Get 1:1 Help
Join the Women’s Club
About

Media
Programs for Women
Professionals
Blog

Pelvic Floor Distress Questionairre

Pelvic Floor Distress Questionaire

Please answer all of the questions in the following survey. These questions will ask you if you have certain bowel, bladder or pelvic symptoms and, if you do, how much they bother you. Answer each questions first by selecting Yes/No and then answer “to what extent.” If you are unsure about how to answer, please give the best answer you can. While answering these questions, please consider your symptoms over the last 3 months.

Name*
First Last
Email*
1- Do you usually experience pressure in the lower abdomen?*
- Yes
- No
1A - To What Extent?*
- Not at all
- Somewhat
- Moderately
- Quite a bit
2- Do you usually experience heaviness or dullness in the lower abdomen?*
- Yes
- No
2A - To What Extent?*
- Not at all
- Somewhat
- Moderately
- Quite a bit
3- Do you usually have a bulge or something falling out that you can see or feel in the vaginal area?*
- Yes
- No
3A - To What Extent?*
- Not at all
- Somewhat
- Moderately
- Quite a bit
4- Do you usually have to push on the vagina or around the rectum to have a complete bowel movement?*
- Yes
- No
4A - To What Extent?*
- Not at all
- Somewhat
- Moderately
- Quite a bit
5- Do you usually experience a feeling of incomplete bladder emptying?*
- Yes
- No
5A - To What Extent?*
- Not at all
- Somewhat
- Moderately
- Quite a bit
6- Do you ever have to push up in the vaginal area with your fingers to start or complete urination?*
- Yes
- No
6A - To What Extent?*
- Not at all
- Somewhat
- Moderately
- Quite a bit
7- Do you feel you need to strain too hard to have a bowel movement?*
- Yes
- No
7A - To What Extent?*
- Not at all
- Somewhat
- Moderately
- Quite a bit
8- Do you feel you have not completely emptied your bowels at the end of a bowel movement?*
- Yes
- No
8A - To What Extent?*
- Not at all
- Somewhat
- Moderately
- Quite a bit
9- Do you usually lose stool beyond your control if your stool is well formed?*
- Yes
- No
9A - To What Extent?*
- Not at all
- Somewhat
- Moderately
- Quite a bit
10- Do you usually lose stool beyond your control if your stool is loose or liquid?*
- Yes
- No
10A - To What Extent?*
- Not at all
- Somewhat
- Moderately
- Quite a bit
11- Do you usually lose gas from the rectum beyond your control?*
- Yes
- No
11A - To What Extent?*
- Not at all
- Somewhat
- Moderately
- Quite a bit
12- Do you usually have pain when you pass your stool?*
- Yes
- No
12A - To What Extent?*
- Not at all
- Somewhat
- Moderately
- Quite a bit
13- Do you experience a strong sense of urgency and have to rush to the bathroom to have a bowel movement?*
- Yes
- No
13A - To What Extent?*
- Not at all
- Somewhat
- Moderately
- Quite a bit
14- Does part of you stool ever pass through the rectum and bulge outside during or after a bowel movement?*
- Yes
- No
14A - To What Extent?*
- Not at all
- Somewhat
- Moderately
- Quite a bit
15- Do you usually experience frequent urination?*
- Yes
- No
15A - To What Extent?*
- Not at all
- Somewhat
- Moderately
- Quite a bit
16- Do you usually experience urine leakage associated with a feeling ofurgency; that is, a strong sensation of needing to go to the bathroom?*
- Yes
- No
16A - To What Extent?*
- Not at all
- Somewhat
- Moderately
- Quite a bit
17- Do you usually experience urine leakage related to laughing, coughing, or sneezing?*
- Yes
- No
17A - To What Extent?*
- Not at all
- Somewhat
- Moderately
- Quite a bit
18- Do you usually experience small amounts of urine leakage (that is, drops)?*
- Yes
- No
18A - To What Extent?*
- Not at all
- Somewhat
- Moderately
- Quite a bit
19- Do you usually experience difficulty emptying your bladder?*
- Yes
- No
19A - To What Extent?*
- Not at all
- Somewhat
- Moderately
- Quite a bit
20- Do you usually experience pain or discomfort in the lower abdomen or genital region?*
- Yes
- No
20A - To What Extent?*
- Not at all
- Somewhat
- Moderately
- Quite a bit

Δ

u00a9 2005 Kathie Hummel-Berry, PT, PhD, Kathe Wallace, PT, Hollis Herman MS, PT, OCSnAll providers of women’s health services are hereby given permission to make unlimited copies for clinical use.

CONTACT US: [email protected]
Terms of Use
Privacy Policy

Site Footer

^