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

    Please answer the below questions in relation to the relevant heading.

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

    Bladder or Urine

    Not at allSomewhatModeratelyQuite a bit

    Bowel or Rectum

    Not at allSomewhatModeratelyQuite a bit

    Vagina or Pelvis

    Not at allSomewhatModeratelyQuite a bit

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

    Bladder or Urine

    Not at allSomewhatModeratelyQuite a bit

    Bowel or Rectum

    Not at allSomewhatModeratelyQuite a bit

    Vagina or Pelvis

    Not at allSomewhatModeratelyQuite a bit

    Entertainment activities such as going to a movie or concert?

    Bladder or Urine

    Not at allSomewhatModeratelyQuite a bit

    Bowel or Rectum

    Not at allSomewhatModeratelyQuite a bit

    Vagina or Pelvis

    Not at allSomewhatModeratelyQuite a bit

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

    Bladder or Urine

    Not at allSomewhatModeratelyQuite a bit

    Bowel or Rectum

    Not at allSomewhatModeratelyQuite a bit

    Vagina or Pelvis

    Not at allSomewhatModeratelyQuite a bit

    Participating in social activities outside your home

    Bladder or Urine

    Not at allSomewhatModeratelyQuite a bit

    Bowel or Rectum

    Not at allSomewhatModeratelyQuite a bit

    Vagina or Pelvis

    Not at allSomewhatModeratelyQuite a bit

    Emotional health (nervousness, depression, etc)?

    Bladder or Urine

    Not at allSomewhatModeratelyQuite a bit

    Bowel or Rectum

    Not at allSomewhatModeratelyQuite a bit

    Vagina or Pelvis

    Not at allSomewhatModeratelyQuite a bit

    Feeling frustrated?

    Bladder or Urine

    Not at allSomewhatModeratelyQuite a bit

    Bowel or Rectum

    Not at allSomewhatModeratelyQuite a bit

    Vagina or Pelvis

    Not at allSomewhatModeratelyQuite a bit