3PSQ - Pelvic Pain Psychological Screening Questionnaire Incontinence Questionnaire Question Title * 1. Please type your name. Surname, First Name Everyone experiences painful situations at some point in their lives. We are interested in the thoughts and feelings that you have when you experience pelvic pain and how you cope with it. Question Title * 2. In the past month: 0 Never 1 Rarely 2 Sometimes 3 Often 4 Always I feel overly stressed I feel overly stressed 0 Never I feel overly stressed 1 Rarely I feel overly stressed 2 Sometimes I feel overly stressed 3 Often I feel overly stressed 4 Always I felt nervous, anxious or on edge I felt nervous, anxious or on edge 0 Never I felt nervous, anxious or on edge 1 Rarely I felt nervous, anxious or on edge 2 Sometimes I felt nervous, anxious or on edge 3 Often I felt nervous, anxious or on edge 4 Always I worried a lot about my health I worried a lot about my health 0 Never I worried a lot about my health 1 Rarely I worried a lot about my health 2 Sometimes I worried a lot about my health 3 Often I worried a lot about my health 4 Always I felt down, depressed or hopeless I felt down, depressed or hopeless 0 Never I felt down, depressed or hopeless 1 Rarely I felt down, depressed or hopeless 2 Sometimes I felt down, depressed or hopeless 3 Often I felt down, depressed or hopeless 4 Always I took little interest or pleasure in doingthings I took little interest or pleasure in doingthings 0 Never I took little interest or pleasure in doingthings 1 Rarely I took little interest or pleasure in doingthings 2 Sometimes I took little interest or pleasure in doingthings 3 Often I took little interest or pleasure in doingthings 4 Always I worried whether something serious waswrong I worried whether something serious waswrong 0 Never I worried whether something serious waswrong 1 Rarely I worried whether something serious waswrong 2 Sometimes I worried whether something serious waswrong 3 Often I worried whether something serious waswrong 4 Always Question Title * 3. In the past month: 0 Never 1 Rarely 2 Sometimes 3 Often 4 Always I couldn’t seem to keep the pain out of mymind I couldn’t seem to keep the pain out of mymind 0 Never I couldn’t seem to keep the pain out of mymind 1 Rarely I couldn’t seem to keep the pain out of mymind 2 Sometimes I couldn’t seem to keep the pain out of mymind 3 Often I couldn’t seem to keep the pain out of mymind 4 Always I paid close attention to my pain I paid close attention to my pain 0 Never I paid close attention to my pain 1 Rarely I paid close attention to my pain 2 Sometimes I paid close attention to my pain 3 Often I paid close attention to my pain 4 Always I could not confidently live a normal lifestyledue to my pain I could not confidently live a normal lifestyledue to my pain 0 Never I could not confidently live a normal lifestyledue to my pain 1 Rarely I could not confidently live a normal lifestyledue to my pain 2 Sometimes I could not confidently live a normal lifestyledue to my pain 3 Often I could not confidently live a normal lifestyledue to my pain 4 Always I felt helpless in being able to reduce or copewith the pain I felt helpless in being able to reduce or copewith the pain 0 Never I felt helpless in being able to reduce or copewith the pain 1 Rarely I felt helpless in being able to reduce or copewith the pain 2 Sometimes I felt helpless in being able to reduce or copewith the pain 3 Often I felt helpless in being able to reduce or copewith the pain 4 Always I was afraid of the pain I was afraid of the pain 0 Never I was afraid of the pain 1 Rarely I was afraid of the pain 2 Sometimes I was afraid of the pain 3 Often I was afraid of the pain 4 Always I tried to avoid anything that caused orworsened my pain I tried to avoid anything that caused orworsened my pain 0 Never I tried to avoid anything that caused orworsened my pain 1 Rarely I tried to avoid anything that caused orworsened my pain 2 Sometimes I tried to avoid anything that caused orworsened my pain 3 Often I tried to avoid anything that caused orworsened my pain 4 Always Question Title * 4. During my life: 0 No 4 Yes I have had a stressful experience or traumatic life event that has had a negative impact on me I have had a stressful experience or traumatic life event that has had a negative impact on me 0 No I have had a stressful experience or traumatic life event that has had a negative impact on me 4 Yes Question Title * 5. If you have been sexually active in the past month, please answer the following: 0 Never 1 Rarely 2 Sometimes 3 Often 4 Always I avoided sexual activity because of my pain I avoided sexual activity because of my pain 0 Never I avoided sexual activity because of my pain 1 Rarely I avoided sexual activity because of my pain 2 Sometimes I avoided sexual activity because of my pain 3 Often I avoided sexual activity because of my pain 4 Always Question Title * 6. If you have been sexually active in the past month, please answer the following: 4 Never 3 Rarely 2 Sometimes 1 Often 0 Always I could say no to sexual activity if I didn’t want it I could say no to sexual activity if I didn’t want it 4 Never I could say no to sexual activity if I didn’t want it 3 Rarely I could say no to sexual activity if I didn’t want it 2 Sometimes I could say no to sexual activity if I didn’t want it 1 Often I could say no to sexual activity if I didn’t want it 0 Always Question Title * 7. Interpretation of scores (for office use only)TOTAL score: (add up scores) = _________ SCORE range: 0 (no Impact) - 60 (highest Impact) Done
