Pelvic Floor Inventory Questionnaire

  • Personal Information

    • Instructions:

    Some women find that bladder, bowel or vaginal symptoms affect their activities, relationships and feelings. For each question choose the response that best describes how much your activities, relationships, or feelings have been affected by your bladder, bowel, or vaginal symptoms or conditions over the last 3 months. Please make sure you answer 3 times for each question, for bladder/urine, bowel/rectum and vagina/pelvis.
  • 1. Ability to do household chores (cooking, cleaning, laundry)?

    For each of the following, how do your symptoms or conditions relating to the following typically affect your lifestyle/emotional health?
  • 2. Ability to do physical activities such as walking, swimming or other exercise?

    For each of the following, how do your symptoms or conditions relating to the following typically affect your lifestyle/emotional health?
  • 3. Entertainment activities such as going to a move or concert?

    For each of the following, how do your symptoms or conditions relating to the following typically affect your lifestyle/emotional health?
  • 4. Ability to travel by car or bus for a distance greater than 30 minutes away from home?

    For each of the following, how do your symptoms or conditions relating to the following typically affect your lifestyle/emotional health?
  • 5. Participating in social activities outside your home?

    For each of the following, how do your symptoms or conditions relating to the following typically affect your lifestyle/emotional health?
  • 6. Emotional health (nervousness, depression, etc.)?

    For each of the following, how do your symptoms or conditions relating to the following typically affect your lifestyle/emotional health?
  • 7. Feeling frustrated?

    For each of the following, how do your symptoms or conditions relating to the following typically affect your lifestyle/emotional health?