Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Date completed *

MM

DD

YYYY

Q1. How many times do you pass urine in a day? *

(0) Up to 7

(1) Between 8-10

(2) Between 11-15

(3) More than 15

Q2. How many times do you get up at night to pass urine? *

(0) 0-1

(1) 2

(2) 3

(3) More than 3 times

Q3. Do you wet the bed before you wake up at night? *

(0) Never

(1) Occasionally - less than once per week

(2) Frequently - once or more per week

(3) Always - every night

Q4. Do you need to rush/hurry to pass urine when you get the urge? *

(0) Can hold on

(1) Occasionally have to rush – less than once/week

(2) Frequently have to rush – once or more/week

(3) Daily

Q5. Does urine leak when you rush or hurry to the toilet or can’t you make it in time? *

(0) Not at all

(1) Occasionally – less than once per week

(2) Frequently – once or more per week

(3) Daily

Q6. Do you leak with coughing, sneezing, laughing or exercising? *

(0) Not at all

(1) Occasionally – less than once per week

(2) Frequently – once or more per week

(3) Daily

Q7. Is your urinary stream (urine flow) weak, prolonged or slow? *

(0) Never

(1) Occasionally – less than once per week

(2) Frequently – once or more per week

(3) Daily

Q8. Do you have a feeling of incomplete bladder emptying? *

(0) Never

(1) Occasionally – less than once per week

(2) Frequently – once or more per week

(3) Daily

Q9. Do you need to strain to empty your bladder? *

(0) Never

(1) Occasionally – less than once per week

(2) Frequently – once or more per week

(3) Daily

Q10. Do you have to wear pads because of urinary leakage? *

(0) None - Never

(1) As a precaution

(2) When exercising / during a cold

(3) Daily

Q11. Do you limit your fluid intake to decrease urinary leakage? *

(0) Never

(1) Before going out

(2) Moderately

(3) Always

Q12. Do you have frequent bladder infections? *

(0) No

(1) 1-3 per year

(2) 4-12 per year

(3) More than one per month

Q13. Do you have pain in your bladder or urethra when you empty your bladder? *

(0) Never

(1) Occasionally – less than once per week

(2) Frequently – once or more per week

(3) Daily

Q14. Does urine leakage affect your routine activities like recreation, socializing, sleeping, shopping etc? *

(0) Not at all

(1) Slightly

(2) Moderately

(3) Greatly

Q15. How much does your bladder problem bother you? *

(0) Not at all

(1) Slightly

(2) Moderately

(3) Greatly

Q16. How often do you usually open your bowels? *

(0) Ever other day or daily

(1) Less than every 3 days

(2) Less than once a week

(3) More than once per day

Q17. How is the consistency of your usual stool? *

(0) Soft

(0) Firm

(0) Hard (pebbles)

(1) Variable

(2) Watery

Q18. Do you have to strain to empty your bowels? *

(0) Never

(1) Occasionally – less than once per week

(2) Frequently – once or more per week

(3) Daily

Q19. Do you use laxatives to empty your bowels? *

(0) Never

(1) Occasionally – less than once per week

(2) Frequently – once or more per week

(3) Daily

Q20. Do you feel constipated? *

(0) Never

(1) Occasionally – less than once per week

(2) Frequently – once or more per week

(3) Daily

Q21. When you get wind or flatus, can you control it, or does wind leak? *

(0) Never

(1) Occasionally – less than once per week

(2) Frequently – once or more per week

(3) Daily

Q22. Do you get an overwhelming sense of urgency to empty bowels? *

(0) Never

(1) Occasionally – less than once per week

(2) Frequently – once or more per week

(3) Daily

Q23. Do you leak watery stool when you don’t mean to? *

(0) Never

(1) Occasionally – less than once per week

(2) Frequently – once or more per week

(3) Daily

Q24. Do you leak normal stool when you don’t mean to? *

(0) Never

(1) Occasionally – less than once per week

(2) Frequently – once or more per week

(3) Daily

Q25. Do you have a feeling of incomplete bowel emptying? *

(0) Never

(1) Occasionally – less than once per week

(2) Frequently – once or more per week

(3) Daily

Q26. Do you use finger pressure to help empty your bowel? *

(0) Never

(1) Occasionally – less than once per week

(2) Frequently – once or more per week

(3) Daily

Q27. How much does your bowel problem bother you? *

(0) Not at all

(1) Slight

(2) Moderately

(3) Greatly

Q28. Do you have a sensation of tissue protrusion/lump/bulging in your vagina? *

(0) Never

(1) Occasionally – less than once per week

(2) Frequently – once or more per week

(3) Daily

Q29. Do you experience vaginal pressure or heaviness or a dragging sensation? *

(0) Never

(1) Occasionally – less than once per week

(2) Frequently – once or more per week

(3) Daily

Q30. Do you have to push back your prolapse in order to void? *

(0) Never

(1) Occasionally – less than once per week

(2) Frequently – once or more per week

(3) Daily

Q31. Do you have to push back your prolapse to empty your bowels? *

(0) Never

(1) Occasionally – less than once per week

(2) Frequently – once or more per week

(3) Daily

Q32. How much does your prolapse bother you? *

(0) Not at all

(1) Slightly

(2) Moderately

(3) Greatly

Q33. Are you sexually active? *

If you are not sexually active, please continue to answer questions 34 & 42.

No

Less than once per week

Once or more per week

Daily or most days

Q34. 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

Q35. Do you have sufficient vaginal lubrication during intercourse?

(0) Yes

(1) No

Q36. During intercourse vaginal sensation is:

(0) Normal / pleasant

(1) Minimal

(1) Painful

(3) None

Q37. Do you feel that your vagina is too loose or lax?

(0) Never

(1) Occasionally

(2) Frequently

(3) Always

Q38. Do you feel that your vagina is too tight?

(0) Never

(1) Occasionally

(2) Frequently

(3) Always

Q39. Do you experience pain with sexual intercourse?

(0) Never

(1) Occasionally

(2) Frequently

(3) Always

Q40. Where does the pain during intercourse occur?

(0) Not applicable, I do not have pain

(1) At the entrance to the vagina

(1) Deep inside, in the pelvis

(2) Both at the entrance & in the pelvis

Q41. Do you leak urine during sexual intercourse?

(0) Never

(1) Occasionally

(2) Frequently

(3) Always

Q42. How much do these sexual issues bother you? *

Not applicable

(0) Not at all

(1) Slightly

(2) Moderately

(3) Greatly

Do you need a pessary prescription? *

Yes

No

I am not sure will talk with my physio

Are you currently pregnant? *

Yes - First Trimester

Yes - Second Trimester

Yes - Third Trimester

No