PGQ - Pelvic Girdle Questionnaire Pelvic Pain Questionnaire Question Title * 1. Please type your name. Surname, First Name To what extent do you find it problematic to carry out the activities listed below because of pelvicgirdle pain? For each activity check ( √ ) the box that best describes how you are today. Question Title * 2. How problematic is it for youbecause of your pelvic girdlepain to: 0 not at all 1 to a small extent 2 to some extent 3 to a large extent Dress yourself Dress yourself 0 not at all Dress yourself 1 to a small extent Dress yourself 2 to some extent Dress yourself 3 to a large extent Stand for less than 10 minutes Stand for less than 10 minutes 0 not at all Stand for less than 10 minutes 1 to a small extent Stand for less than 10 minutes 2 to some extent Stand for less than 10 minutes 3 to a large extent Stand for more than 60 minutes Stand for more than 60 minutes 0 not at all Stand for more than 60 minutes 1 to a small extent Stand for more than 60 minutes 2 to some extent Stand for more than 60 minutes 3 to a large extent Bend down Bend down 0 not at all Bend down 1 to a small extent Bend down 2 to some extent Bend down 3 to a large extent Sit for less than 10 minutes Sit for less than 10 minutes 0 not at all Sit for less than 10 minutes 1 to a small extent Sit for less than 10 minutes 2 to some extent Sit for less than 10 minutes 3 to a large extent Sit for more than 60 minutes Sit for more than 60 minutes 0 not at all Sit for more than 60 minutes 1 to a small extent Sit for more than 60 minutes 2 to some extent Sit for more than 60 minutes 3 to a large extent Walk for less than 10 minutes Walk for less than 10 minutes 0 not at all Walk for less than 10 minutes 1 to a small extent Walk for less than 10 minutes 2 to some extent Walk for less than 10 minutes 3 to a large extent Walk for more than 60 minutes Walk for more than 60 minutes 0 not at all Walk for more than 60 minutes 1 to a small extent Walk for more than 60 minutes 2 to some extent Walk for more than 60 minutes 3 to a large extent Climb stairs Climb stairs 0 not at all Climb stairs 1 to a small extent Climb stairs 2 to some extent Climb stairs 3 to a large extent Do housework Do housework 0 not at all Do housework 1 to a small extent Do housework 2 to some extent Do housework 3 to a large extent Question Title * 3. How problematic is it for you because of your pelvic girdle pain to: 0 not at all 1 to a small extent 2 to some extent 3 to a large extent Carry light objects Carry light objects 0 not at all Carry light objects 1 to a small extent Carry light objects 2 to some extent Carry light objects 3 to a large extent Carry heavy objects Carry heavy objects 0 not at all Carry heavy objects 1 to a small extent Carry heavy objects 2 to some extent Carry heavy objects 3 to a large extent Get up/sit down Get up/sit down 0 not at all Get up/sit down 1 to a small extent Get up/sit down 2 to some extent Get up/sit down 3 to a large extent Push a shopping cart Push a shopping cart 0 not at all Push a shopping cart 1 to a small extent Push a shopping cart 2 to some extent Push a shopping cart 3 to a large extent Run Run 0 not at all Run 1 to a small extent Run 2 to some extent Run 3 to a large extent Carry out sporting activities (leave blank if N/A) Carry out sporting activities (leave blank if N/A) 0 not at all Carry out sporting activities (leave blank if N/A) 1 to a small extent Carry out sporting activities (leave blank if N/A) 2 to some extent Carry out sporting activities (leave blank if N/A) 3 to a large extent Lie down Lie down 0 not at all Lie down 1 to a small extent Lie down 2 to some extent Lie down 3 to a large extent Roll over in bed Roll over in bed 0 not at all Roll over in bed 1 to a small extent Roll over in bed 2 to some extent Roll over in bed 3 to a large extent Have a normal sex life (leave blank if N/A) Have a normal sex life (leave blank if N/A) 0 not at all Have a normal sex life (leave blank if N/A) 1 to a small extent Have a normal sex life (leave blank if N/A) 2 to some extent Have a normal sex life (leave blank if N/A) 3 to a large extent Push something with one foot Push something with one foot 0 not at all Push something with one foot 1 to a small extent Push something with one foot 2 to some extent Push something with one foot 3 to a large extent Question Title * 4. How much pain do you experience: 0 none 1 some 2 moderate 3 considerable In the morning In the morning 0 none In the morning 1 some In the morning 2 moderate In the morning 3 considerable In the evening In the evening 0 none In the evening 1 some In the evening 2 moderate In the evening 3 considerable Question Title * 5. To what extent because of pelvic girdle pain: 0 not at all 1 to a small extent 2 to some extent 3 to a large extent Has your leg/haveyour legs given way Has your leg/haveyour legs given way 0 not at all Has your leg/haveyour legs given way 1 to a small extent Has your leg/haveyour legs given way 2 to some extent Has your leg/haveyour legs given way 3 to a large extent Do you do thingsmore slowly Do you do thingsmore slowly 0 not at all Do you do thingsmore slowly 1 to a small extent Do you do thingsmore slowly 2 to some extent Do you do thingsmore slowly 3 to a large extent Is your sleepinterrupted Is your sleepinterrupted 0 not at all Is your sleepinterrupted 1 to a small extent Is your sleepinterrupted 2 to some extent Is your sleepinterrupted 3 to a large extent Question Title * 6. Interpretation of scores (for office use only)TOTAL % Disability score: (add up scores________/75)x100 = __________ *note if no response for sex or sport question, reduce to divide by 75-3 for each answer not given*SCORE range: 0 (no disability) - 100 (highest disability) Reference: Stuge B, Garratt A, Jenssen H, Grotle M. The Pelvic Girdle Questionnaire: A Condition Specific Instrument for Assessing Activity Limitations and Symptoms in People with Pelvic Girdle Pain. Physical Therapy. July 2011; 91(7): 10961108. Done
