The Pelvic Pain Impact Questionnaire

The Pelvic Pain Impact Questionnaire
Name*

First NameLast Name
Date*

MonthDayYear
Date
Directions:
For each of the following 8 questions, tick the box that best indicates how much your pelvic pain has affected these aspects of your life during the past month.

Your answers to these questions can then be summed to give you a final score.

energy levels?

	0	1	2	3	4

0 is Not at all, 4 is A great deal

mood?

	0	1	2	3	4

0 is Not at all, 4 is A great deal

sleep?

	0	1	2	3	4

0 is Not at all, 4 is A great deal

stomach and intestinal function?

	0	1	2	3	4

0 is Not at all, 4 is A great deal

ability to sit for longer than 20 minutes?

	0	1	2	3	4

0 is Not at all, 4 is A great deal

ability to perform and function normally athome/work/school/university?

	0	1	2	3	4

0 is Not at all, 4 is A great deal

ability to take part in physical activity?(e.g. jogging, yoga, bicycling)

	0	1	2	3	4

0 is Not at all, 4 is A great deal

ability to wear certain clothes?(e.g. underwear, tight fitting clothes)

	0	1	2	3	4

0 is Not at all, 4 is A great deal