Vulvar Pain Functional Questionnaire

Personal Information & History

Name

First Last

Today's Date

Who is your therapist?

Questionnaire

These are statements about how your pelvic pain affects your everyday life. Please check on box for each item below, choosing the one that best describes your situation. Some of the statements deal with personal subjects. These statements are included because they will help your health care provider design the best treatment for you and your progress during treatment. Your responses will be kept completely confidential at all times.

1. Because of my pelvic pain*

I can’t wear tight fitting clothing like pantyhose that puts any pressure over my painful areas. [3 points]
I can wear closer fitting clothing as long as it only puts a little bit of pressure over my painful area. [2 point]
I can wear whatever I like most of the time, but every now and then I feel pelvic pain caused by pressure from my clothing. [1 point]
I can wear whatever I like; I never have pelvic pain because of clothing. [0 points]

2. My pelvic pain*

Gets worse when I walk, so I can only walk far enough to move around in my house, no further. [3 points]
Gets worse when I walk. I can walk a short distance outside the house, but it is very painful to walk far enough to get a full load of groceries in a grocery store. [2 points]
Gets a little worse when I walk. I can walk far enough to do my errands, like grocery shopping, but it would be very painful to walk longer distances for fun or exercise. [1 point]
My pain does not get worse with walking, I can walk as far as I want. [0 points]
I have a hard time walking because of another medical problem, but pelvic pain doesn’t make it hard to walk. [0 points]

3. My pelvic pain*

Gets worse when I sit, so it hurts too much to sit any longer than 30 minutes at a time. [3 points]
Gets worse when I sit. I can sit for longer than 30 minutes at a time, but it is so painful that is difficult to do my job or sit long enough to watch a movie. [2 points]
Occasionally gets worse when I sit, but most of the time sitting is comfortable. [1 point]
I have trouble sitting for very long because of another medical problem, but pelvic pain doesn’t make it hard to sit. [0 points]

4. Because of pain pills I take for my pelvic pain*

I am sleepy and I have trouble concentrating at work or while I do housework. [3 points]
I can concentrate just enough to do my work, but I can’t do more, like go out in the evenings. [2 points]
I don’t have any problems with the pills that I take for pelvic pain. [1 point]
I don’t take pain pills for my pelvic pain. [0 points]

5. Because of my pelvic pain*

I have very bad pain when I try to have a bowel movement, and it keeps hurting for at least 5 minutes after I am finished. [3 points]
It hurts when I try to have a bowel movement, but the pain goes away when I am finished. [2 point]
Most of the time it does not hurt when I have a bowel movement, but every now and then it does. [1 point]
It never hurts from my pelvic pain when I have a bowel movement. [0 points]

6. Because of my pelvic pain*

I don’t get together with my friends or go out to parties or events. [3 points]
I only get together with my friends or go out to parties or events every now and then. [2 points]
I usually will go out with friends or to events if I want to, but every now and then I don’t because of the pain. [1 point]
I get together with friends or go to events whenever I want, pelvic pain does not get in the way. [0 points]

7. Because of my pelvic pain*

I can’t stand for the doctor to insert the speculum when I go to the gynecologist. [3 points]
I can stand it when the doctor inserts the speculum if they are very careful, but most of the time it really hurts. [2 points]
It usually doesn’t hurt when the doctor inserts the speculum, but every now and then it does hurt. [1 point]
It never hurts for the doctor to insert the speculum when I go to the gynecologist. [0 points]

8. Because of my pelvic pain*

I cannot use tampons at all, because they make my pain much worse. [3 points]
I can only use tampons if I put them in very carefully. [2 points]
It usually doesn’t hurt to use tampons, but occasionally it does hurt. [1 point]
This question doesn’t apply to me, because I don’t need to use tampons, or I wouldn’t choose to use them whether they hurt or not. [0 points]

9. Social Life*

I can’t let my partner put a finger or penis in my vagina during sex at all. [3 points]
My partner can put a finger or penis in my vagina very carefully, but it still hurts. [2 point]
It usually doesn’t hurt if my partner puts a finger or penis in my vagina, but every now and then it does hurt. [1 point]
It doesn’t hurt to have my partner put a finger or penis in my vagina at all. [0 points]
This question does not apply to me because I don’t have a sexual partner. [0 points]
Specifically, I won’t get involved with a partner because I worry about pelvic pain during sex. [0 points]

10. Because of my pelvic pain*

It hurts too much for my partner to touch me sexually even if the touching doesn’t go in my vagina. [3 points]
My partner can touch me sexually outside the vagina if we are very careful. [2 points]
It doesn’t usually hurt for my partner to touch me sexually outside the vagina but every now and then it does hurt. [1 point]
It never hurts for my partner to touch me sexually outside the vagina. [0 points]
This question does not apply to me because I don’t have a sexual partner. [0 points]
Specifically, I won’t get involved with a partner because I worry about pelvic pain during sex. [0 points]

11. Because of my pelvic pain*

It is too painful to touch myself for sexual pleasure. [3 points]
I can touch myself for sexual pleasure if I am very careful. [2 points]
It usually doesn’t hurt to touch myself for sexual pleasure, but every not and then it does hurt. [1 point]
It never hurts to touch myself for sexual pleasure. [0 points]
I don’t touch myself for sexual pleasure, but that is by choice not because of pelvic pain. [0 points]