Patient Questionnaire

Question Title

* 1. Please type your name. Surname, First Name

Instructions: Those with Pelvic Floor Dysfunction find that bladder, bowel, or vaginal symptoms affect their activities, relationships, and feelings. For each question, check the response that best describes how much your activities, relationships, or feelings have been affected by your bladder, bowel and vaginal / pelvic symptoms or conditions over the last 3 months.

Please be sure to mark an answer in all 3 columns for each question.

Question Title

* 2. How do symptoms or conditions in the following usually affect your ability to do household chores (cooking, laundry housecleaning)?

  0 not at all 1 somewhat 2 moderately 3 quite a bit
Bladder or Urine
Bowel or Rectum
Vagina or Pelvis

Question Title

* 3. How do symptoms or conditions in the following usually affect your ability to do physical activities such as walking, swimming, or other exercise?

  0 not at all 1 somewhat 2 moderately 3 quite a bit
Bladder or Urine
Bowel or Rectum
Vagina or Pelvis

Question Title

* 4. How do symptoms or conditions in the following usually affect your entertainment activities such as going to a movie or concert?

  0 not at all 1 somewhat 2 moderately 3 quite a bit
Bladder or Urine
Bowel or Rectum
Vagina or Pelvis

Question Title

* 5. How do symptoms or conditions in the following usually affect your ability to travel by car or bus for a distance greater than 30 minutes away from home?

  0 not at all 1 somewhat 2 moderately 3 quite a bit
Bladder or Urine
Bowel or Rectum
Vagina or Pelvis

Question Title

* 6. How do symptoms or conditions in the following usually affect your ability to participate in social activities outside your home?

  0 not at all 1 somewhat 2 moderately 3 quite a bit
Bladder or Urine
Bowel or Rectum
Vagina or Pelvis

Question Title

* 7. How do symptoms or conditions in the following usually affect your emotional health (nervousness, depression, etc)?

  0 not at all 1 somewhat 2 moderately 3 quite a bit
Bladder or Urine
Bowel or Rectum
Vagina or Pelvis

Question Title

* 8. How do symptoms or conditions in the following usually affect you feeling frustrated?

  0 not at all 1 somewhat 2 moderately 3 quite a bit
Bladder or Urine
Bowel or Rectum
Vagina or Pelvis

Question Title

* 9. Interpretation of scores (for office use only)
PFIQ-7 Summary Score
= (sum of scores ________)/63)*100=__________

Interpretation:
Low score (0-33): Indicates minimal impact on daily life from pelvic floor symptoms.
Moderate score (34-66): Suggests moderate interference with activities due to pelvic floor issues.
High score (67-100): Represents a significant negative impact on quality of life related to pelvic floor symptoms.

Can be broken into subscales including:
A: Urinary Impact Questionnaire (UIQ-7): 7 items under column heading “Bladder or urine”
= (total score under bladder or urine _______/21)*100=________
B: Colorectal-Anal Impact questionnaire (CRAIQ-7): 7 items under column heading “Bowel / rectum”
= (total score under bowel or rectum _______/21)*100=________
C: Pelvic Organ Prolapse Impact Questionnaire (POPIQ-7): Items under column “Pelvis / Vagina”
= (total score under vagina or pelvis_______/21)*100=________