Pelvic Pain Impact Questionnaire

Name*

First NameLast Name

Date of Birth*

DayMonthYear

Date*

DayMonthYear

How much has your pain affected you over the past month.

	Not at all	A bit	Somewhat	Quite a bit	A great deal
Energy levels
Mood
Sleep
Stomach and intestinal function
Ability to sit for more than 20 minutes
Ability to function normally at home/work
Ability to do physical activity
Ability to wear certain clothes

If the following questions don't relate to you then don't answer them,

if they do then answer them.

	Not at all	A bit	Somewhat	Quite a bit	A great deal
How much did pelvic pain affect your ability to do tampons?
How much has pelvic pain affected you levels of intimacy or sexual relationships?