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Newsletters
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Patient Education & Resources
Patient Education & Resources
Australian Pelvic Floor Questionnaire Form
Australian Pelvic Floor Questionnaire
THE AUSTRALIAN PELVIC FLOOR QUESTIONNAIRE
Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Date completed
*
MM
DD
YYYY
BLADDER FUNCTION
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
Other symptoms (haematuria, pain etc.)
BOWEL FUNCTION
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
PROLAPSE SYMPTOMS
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
Other Symptoms: (problems: walking / sitting, pain, vaginal bleeding)
SEXUAL FUNCTION
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
Q43. Other symptoms? (faecal incontinence, vaginismus etc)
What is the reason you need to see a women's health physiotherapist?
*
Leakage, prolapse, pelvic pain, bowel problems, pregnancy check-up, pelvic girdle pain, mastitis,
What is the name of your referring doctor/s?
If you are self referring you can leave it blank
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
Thank you for completing the Pelvic Floor Questionnaire!
Therapeutic Ultrasound for Blocked Ducts and Mastitis Brochure
Macarthur Women's Health Services Brochure
Internal Examination Information Sheet
Pessary Information Sheet
Bladder Diary
Bowel Diary