Pelvic Floor Questionnaire

Pelvic Floor Questionnaire

Your Full Name*

Your Email*

What is the reason(s) for your consultation?

How much do each of these bother you out of 10?
 1 2 3 4 5 6 7 8 9 10

What are your goals?

Bladder Behaviour

How many minutes or hours between emptying your bladder in waking hours?*

During sleep hours?*

When you empty your bladder do you have any of the following:
 Difficulty starting Not feeling empty Pain with emptying or at end of weeing Deviated stream Intermittent stream Slow stream throughout Dribbling after weeing Needing to go back and empty a short time after

Any history of urinary tract infections? If so how often?*

What (water, coffee etc) and how much do you drink on average per day?*

Incontinence and/or Urgency

Please fill out the following questions if you have symptoms of leakage or urgency.

If you leak, what activities or circumstances take place to make this happen?*

If there is leakage, how much? Eg. 5c piece in underwear, ½ underwear, through to pants?*

Do you wear pads? If so, what type? How many per day?

If you have urgency, are there triggers or circumstances that trigger the urgency?*

Bowel Behaviour

How often do you empty your bowels?

What Type does it look like on average or what range? (Refer to chart below)
 Type 1 Type 2 Type 3 Type 4 Type 5 Type 6 Type 7

Do you have any of the following with your bowels:
 Straining Urgency Don’t feel empty Use lots of toilet paper to wipe Leakage/Staining

Further information


Please fill this section if the following applies to you.

Do you get:
 Painful periods Heavy bleding?

How long have you had this for?

Prolapse Symptoms

Please fill this section if you have symptoms of heaviness, dragging or bulging sensation around the vagina.

Do you get:
 Dragging Bulging Heaviness Ache

Is it worse with a certain activity or time of day?

Surgical/Obstetric History

How many children have you had?*

How many vaginal and how many caesarean births?*

Any other surgical history in the abdomen, back or pelvis?*

Sexual intercourse

Please fill out this section if it is applicable.

Do you have vaginal and/or anal intercourse?
 Vaginal intercourse Anal intercourse

Is there any pain with any of these?

If yes to any is there a particular position that causes these symptoms?

Is there any leakage with any of these?

Are there any other issues in respect to sexual intercourse you would like addressed? (eg. Lubrication, libido, orgasm, thrush)