Pelvic floor questionnaire



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PELVIC FLOOR QUESTIONNAIRE



Name____________________________________________ Age: _________ Weight: _________
Occupation_______________________________Employer________________________________Hours worked per week__________
What are your symptoms? ___________________________________________________________________________________
When did symptoms start? (Onset Date) ___________Surgery Date ___________Where did you have surgery? ____________
Cause of symptoms? _________________________________________________________________________________________
Since onset, your symptoms are:  Worse  Same  Better Prior to this onset, were you symptom free?  Yes  No
What increases your symptoms? _______________________________________________________________________________
What decreases your symptoms? _______________________________________________________________________________

(Worst pain

Please rate your current pain (circle): (No pain) (Moderate) imaginable)

0 1 2 3 4 5 6 7 8 9 10

Daily Activities: Home/Leisure Limitations__________________________________________________________________
Self-Care Limitations______________________________________________________________________

Do you exercise? _______ How often? _______________ Type ___________________________________
Medical History:


MEDICATIONS & ALLERGIES

Please list (or provide us with a separate list) of any medications you are currently taking and any allergies you have

MEDICATION:










 Refer to attached medication list provided by patient










ALLERGIES:

MEDICAL DIAGNOSES AND CONDITIONS Please check those current or past items that apply to you

General Health

 Fatigue Weight change Fever Chills Night sweats Recent illness Excess Thirst  Cancer  Diabetes Thyroid problem Bleeding Anxiety Depression Bipolar disorder  Back Pain

describe:



Lungs/Breathing

 Coughing  Asthma  Allergy  Emphysema  COPD

 Smoker (if yes, how many packs per day?______)



Gastrointestinal/

Stomach/Urinary

 Nausea Vomiting Kidney disease Hiatal hernia Reflux Heartburn  Trouble swallowing  Irritable bowel syndrome  Constipation  Diarrhea  Interstitial cystitis

Genitourinary

 Currently pregnant (If yes, how many weeks?)_____

 Incontinence (circle) Bladder/Bowel  Prostate problems  Infections  Frequent or painful urination



Musculoskeletal

 Back/neck/joint problems  Osteoporosis

Skin

 Rash  Bruise easily  Open sores  Recent tattoos  Psoriasis  Eczema

Neurological

 Stroke  Parkinson’s  MS  Fibromyalgia

Please list any other Conditions not noted above:




What previous treatments or tests have you had?




 X-Rays  CT Scan  MRI  Injections  EMG  Other ________________________________________________




Please list any surgeries you have had and when:








Ob/Gyn History (Females Only)

Yes No

Births: vaginal # ____ c-section #____

Yes No

Menopause - When?

Yes No

Difficult childbirth

Yes No

Pelvic/genital pain

Yes No

Vaginal dryness

Yes No

Hysterectomy

Yes No

Pregnant or attempting pregnancy

Yes No

IUD in place

Yes No

Prolapse/Rectocele/Cystocele

Yes No

Endometriosis

Yes No

Painful Menstruation







Comments:


Males Only

Yes No

Prostate disorders

Yes No

Erectile Dysfunction

Yes No

Shy bladder

Yes No

Painful Ejaculation

Yes No

Pelvic/genital pain

Yes No

Hernia – Where?

Comments:





Bladder Symptoms

Yes No

Trouble initiating urine stream

Yes No

Dribbling after urination

Yes No

Urine intermittent/slow stream

Yes No

Constant urine leakage

Yes No

Strain or push to empty bladder

Yes No

Trouble feeling bladder urge/fullness

Yes No

Need to urinate with little warning

Yes No

Recurrent bladder infections

Yes No

Trouble emptying bladder completely

Yes No

Painful urination

Yes No

Blood in urine

Yes No

Volume passed __small __med __large

Comments:


Urinary Habits

Frequency of urination: Every ____minutes; Every ____ hours; ____times per day; ____times per night

On average, how much do you leak? None Just a few drops Wet underwear Wet the floor Soaked pads

Can you delay before you go to toilet? _____ minutes (# of minutes) _____hours (# of hours) Not at all

Bladder leakage: # of episodes: None without awareness with exertion/cough with urge

____times/day; ____times/week; ____times/month



What form of protection do you wear? None

Minimal protection (toilet paper/pantishield)

Moderate protection (absorbent product/maxipad)

Maximum protection (specialty product/diaper)



On average, how many pad changes are required during daytime? _____(#of pads) at night?____(#of pads)

Are they damp____ wet _____ soaked_____



Average fluid intake (1glass = 8 oz) ____# glasses/day

Of this total how many glasses are: Caffeinated? ____# glasses/day Fruit drinks? ____# glasses/day



Alcoholic? ____# glasses/day Water? ____# glasses/day

Comments:


Bowel History

Yes No

Blood in bowel movement (BM)

Yes No

Trouble emptying bowel completely

Yes No

Painful BM

Yes No

Need to support/splint to complete BM

Yes No

Trouble feeling bowel urge

Yes No

Constipation/straining ____% of time

Yes No

Trouble holding back gas

Yes No

Current laxative use

Yes No

Trouble starting BM

Yes No

Fecal leakage ___times/day ___times/week

Comments:


Bowel Symptoms

Frequency of bowel movements: ____times/day; ____times/week

When you have the urge to have a bowel movement, how long can you delay? Minutes Hours Not at all

Bowel movements are typically:  Watery  Loose  Formed  Pellets  Thin  Hard

If constipation is present, describe management techniques:


Comments:





Rate a feeling of organ ”falling out”/prolapse or pelvic heaviness/pressure

 None present

 With standing for ____minutes or ____hours

 With exertion or straining

 With menses

 Pressure at end of the day

 Pressure all day

Comments:





Sexual History

Yes No

Sexually active

Yes No

Pain with initial entry

Yes No

Pain with penetration

Yes No

Pain with deep thrust

If Yes,

Yes No

with tampon (females)

Yes No

Bleeding with or following intercourse




Yes No

with speculum(females)

Yes No

History of sexual abuse




Yes No

Pain w/erection(males)

Comments:





Yes No

Pain w/ejaculation (males)




Activities that cause or aggravate any of your bladder/bowel symptoms or pain (check all that apply)

Sitting greater than ____minutes

Laughing/yelling

Walking greater than ____minutes

Lifting/bending

Standing greater than ____minutes

Cold weather

Changing positions (sit to stand)

Triggers (key in the door/running the water)

Light activity (light housework)

Nervousness/anxiety

Vigorous activity/exercise (run, weight lift, jump)

Sleeping

Sexual activity

No activity affects the problem

Cough/sneeze/straining




Comments:

Please list your goals. (What do you want this treatment to do for you?) __________________________________________________



____________________________________________________________________________________________________________


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