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About us
New Patients
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Physiotherapy
Sports Injury
Post-Op Rehab
Paediatric Physiotherapy
Women’s Health
Massage Therapies
Shockwave Clinic
Running Analysis
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Vestibular Rehabilitation
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What We Treat
Pricing
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Golders Green
Elstree
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Australian Pelvic Floor Questionnaire
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Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 5
Patient's Name
*
Date of Birth
Date Completed
Let's Do This
Bladder Function
How many times do you pass urine in a day?
Up to 7
Between 8-10
Between 11-15
More than 15
How many times do you get up at night to pass urine?
0-1
2
3
More than 3 times
Do you wet the bed before you wake up at night?
Never
Occasionally - less than once per week
Frequently - once or more per week
Always - every night
Do you need to rush/hurry to pass urine when you get the urge?
Can hold on
Occasionally have to rush – less than once/week
Frequently have to rush – once or more/week
Daily
Does urine leak when you rush or hurry to the toilet or can’t you make it in time?
Not at all
Occasionally – less than once per week
Frequently – once or more per week
Daily
Do you leak with coughing, sneezing, laughing or exercising?
Not at all
Occasionally – less than once per week
Frequently – once or more per week
Daily
Is your urinary stream (urine flow) weak, prolonged or slow?
Never
Occasionally – less than once per week
Frequently – once or more per week
Daily
Do you have a feeling of incomplete bladder emptying?
Never
Occasionally – less than once per week
Frequently – once or more per week
Daily
Do you need to strain to empty your bladder?
Never
Occasionally – less than once per week
Frequently – once or more per week
Daily
Do you have to wear pads because of urinary leakage?
None - Never
As a precaution
When exercising / during a cold
Daily
Do you limit your fluid intake to decrease urinary leakage?
Never
Before going out
Moderately
Always
Do you have frequent bladder infections?
No
1-3 per year
4-12 per year
More than one per month
Do you have pain in your bladder or urethra when you empty your bladder?
Never
Occasionally – less than once per week
Frequently – once or more per week
Daily
Does urine leakage affect your routine activities like recreation, socializing, sleeping, shopping etc?
Not at all
Slightly
Moderately
Greatly
How much does your bladder problem bother you?
Not at all
Slightly
Moderately
Greatly
Other symptoms (haematuria, pain etc.)
Back
Next
Bowel Function
How often do you usually open your bowels?
Ever other day or daily
Less than every 3 days
Less than once a week
More than once per day
How is the consistency of your usual stool?
Soft
Firm
Hard (pebbles)
Variable
Watery
Do you have to strain to empty your bowels?
Never
Occasionally – less than once per week
Frequently – once or more per week
Daily
Do you use laxatives to empty your bowels?
Never
Occasionally – less than once per week
Frequently – once or more per week
Daily
Do you feel constipated?
Never
Occasionally – less than once per week
Frequently – once or more per week
Daily
When you get wind or flatus, can you control it, or does wind leak?
Never
Occasionally – less than once per week
Frequently – once or more per week
Daily
Do you get an overwhelming sense of urgency to empty bowels?
Never
Occasionally – less than once per week
Frequently – once or more per week
Daily
Do you leak watery stool when you don’t mean to?
Never
Occasionally – less than once per week
Frequently – once or more per week
Daily
Do you leak normal stool when you don’t mean to?
Never
Occasionally – less than once per week
Frequently – once or more per week
Daily
Do you have a feeling of incomplete bowel emptying?
Never
Occasionally – less than once per week
Frequently – once or more per week
Daily
Do you use finger pressure to help empty your bowel?
Never
Occasionally – less than once per week
Frequently – once or more per week
Daily
How much does your bowel problem bother you?
Not at all
Slightly
Moderately
Greatly
Next
Prolapse Symptoms
Do you have a sensation of tissue protrusion/lump/bulging in your vagina?
Never
Occasionally – less than once per week
Frequently – once or more per week
Daily
Do you experience vaginal pressure or heaviness or a dragging sensation?
Never
Occasionally – less than once per week
Frequently – once or more per week
Daily
Do you have to push back your prolapse in order to void?
Never
Occasionally – less than once per week
Frequently – once or more per week
Daily
Do you have to push back your prolapse to empty your bowels?
Never
Occasionally – less than once per week
Frequently – once or more per week
Daily
How much does your prolapse bother you?
Not at all
Slightly
Moderately
Greatly
Other Symptoms: (problems: walking / sitting, pain, vaginal bleeding)
Next
Sexual Function
Are you sexually active?
No
Less than once per week
Once or more per week
Daily or most days
If you are not sexually active, please continue to answer questions 34 & 42
If you are not sexually active, please tell us why?
Do not have a partner
I am not interested
My partner is unable
Vaginal dryness
Too painful
Embarrassment due to the prolapse/incontinence
Other reasons
Do you have sufficient vaginal lubrication during intercourse?
Yes
No
During intercourse vaginal sensation is:
Normal / pleasant
Minimal
Painful
None
Do you feel that your vagina is too loose or lax?
Never
Occasionally
Frequently
Always
Do you feel that your vagina is too tight?
Never
Occasionally
Frequently
Always
Do you experience pain with sexual intercourse?
Never
Occasionally
Frequently
Always
Where does the pain during intercourse occur?
Not applicable, I do not have pain
At the entrance to the vagina
Deep inside, in the pelvis
Both at the entrance & in the pelvis
Do you leak urine during sexual intercourse?
Never
Occasionally
Frequently
Always
How much do these sexual issues bother you?
Not applicable
Not at all
Slightly
Moderately
Greatly
Other symptoms?
(faecal incontinence, vaginismus etc)
Submit
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About us
New Patients
Sponsored Athlete Program
FAQs
Meet the team
Services
Physiotherapy
Sports Injury
Post-Op Rehab
Paediatric Physiotherapy
Women’s Health
Massage Therapies
Shockwave Clinic
Running Analysis
TMJ Rehab
Vestibular Rehabilitation
Physical Therapy For Disabilities
What We Treat
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Hatfield
Golders Green
Elstree
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