Please answer each question by checking the best response. While answering these questions, please consider your symptoms over the last 3 months. We realise that you may not be having problems in some of these areas but please fill out both sides of this form as completely as possible.

Urinary Distress Inventory 6 (UDI-6)

Do you experience, and if so, how much are you bothered by…..

Usually experience frequent urination?

Not at allSomewhatModeratelyQuite a bit

Usually experience urine leakage associated with a feeling of urgency, this is, a strong sensation of needing to go to the bathroom?

Not at allSomewhatModeratelyQuite a bit

Usually experience urine leakage related to coughing, sneezing, or laughing?

Not at allSomewhatModeratelyQuite a bit

Usually experience small amounts of urine leakage (that is, drops)?

Not at allSomewhatModeratelyQuite a bit

Usually experience difficulty emptying your bladder?

Not at allSomewhatModeratelyQuite a bit

Usually experience pain or discomfort in the lower abdomen or genital region?

Not at allSomewhatModeratelyQuite a bit

Colorectal-Anal Distress Inventory 8 (CRADI-8)

Do you experience, and if so, how much are you bothered by…..

Feel you need to strain too hard to have a bowel movement?

Not at allSomewhatModeratelyQuite a bit

Feel you have not completely emptied your bowel at the end of a bowel movement?

Not at allSomewhatModeratelyQuite a bit

Usually lose stool beyond your control if your stool is well formed?

Not at allSomewhatModeratelyQuite a bit

Usually lose stool beyond your control if your stool is loose?

Not at allSomewhatModeratelyQuite a bit

Usually lose gas from the rectum beyond your control?

Not at allSomewhatModeratelyQuite a bit

Do you usually have pain when you pass your stool?

Not at allSomewhatModeratelyQuite a bit

Experience a strong sense of urgency and have to rush to the bathroom to have a bowel movement?

Not at allSomewhatModeratelyQuite a bit

Does part of your bowel ever pass through the rectum and bulge outside during or after a bowel movement?

Not at allSomewhatModeratelyQuite a bit

Pelvic Organ Prolapse Distress Inventory 6 (POPDI-6)

Do you experience, and if so, how much are you bothered by…..

Usually experience pressure in the lower abdomen?

Not at allSomewhatModeratelyQuite a bit

Usually experience heaviness or dullness in the pelvic area?

Not at allSomewhatModeratelyQuite a bit

Usually have a bulge or something falling out that you can see or feel in your vaginal area?

Not at allSomewhatModeratelyQuite a bit

Ever have to push on the vagina or around the rectum to have or complete a bowel movement?

Not at allSomewhatModeratelyQuite a bit

Usually experience a feeling of incomplete bladder emptying?

Not at allSomewhatModeratelyQuite a bit

Ever have to push up on the bulge in the vaginal area with your fingers to start or complete urination?

Not at allSomewhatModeratelyQuite a bit

Pelvic Floor Impact Questionnaire

How do symptoms or conditions relate to the following →→→ Usually affect your ↓

Ability to do household chores (cooking, housecleaning, laundry)?

Ability to do physical activities such as walking, swimming, or other exercise?

Entertainment activities such as going to a movie or concert?

Ability to travel by car or bus for a distance greater that 30 minutes away from home?

Participating in social activities outside your home

Emotional health (nervousness, depression, etc)?

Feeling frustrated?

Bladder or Urine

 

Not at allSomewhatModeratelyQuite a bit

Not at allSomewhatModeratelyQuite a bit

Not at allSomewhatModeratelyQuite a bit

Not at allSomewhatModeratelyQuite a bit

Not at allSomewhatModeratelyQuite a bit

Not at allSomewhatModeratelyQuite a bit

Not at allSomewhatModeratelyQuite a bit

Bowel or Rectum

 

Not at allSomewhatModeratelyQuite a bit

Not at allSomewhatModeratelyQuite a bit

Not at allSomewhatModeratelyQuite a bit

Not at allSomewhatModeratelyQuite a bit

Not at allSomewhatModeratelyQuite a bit

Not at allSomewhatModeratelyQuite a bit

Not at allSomewhatModeratelyQuite a bit

Vagina or Pelvis

 

Not at allSomewhatModeratelyQuite a bit

Not at allSomewhatModeratelyQuite a bit

Not at allSomewhatModeratelyQuite a bit

Not at allSomewhatModeratelyQuite a bit

Not at allSomewhatModeratelyQuite a bit

Not at allSomewhatModeratelyQuite a bit

Not at allSomewhatModeratelyQuite a bit