Pelvic Floor Assessment Form
Many people suffer from symptoms caused by a weak pelvic floor. We are trying to find what symptoms this can cause and how effective our pelvic floor treatment is at improving them. We would be grateful if you could answer the following questions, thinking about how you have been, on average, over the PAST FOUR WEEKS.
Study number
Are you aware of a dragging discomfort in your lower abdomen?
*
never
occasionally
sometimes
often
always
If so how much does this bother you?
Not at all
1
2
3
4
5
6
7
8
9
A great deal
10
1 is Not at all, 10 is A great deal
Do you feel that your vagina is too loose or lax?
*
not at all
a little
somewhat
a lot
If so how much does this bother you?
Not at all
1
2
3
4
5
6
7
8
9
A great deal
10
1 is Not at all, 10 is A great deal
Are you aware of a lump or bulge coming down in your vagina?
*
never
occasionally
sometimes
often
always
If so, how much does this bother you?
Not at all
1
2
3
4
5
6
7
8
9
A great deal
10
1 is Not at all, 10 is A great deal
Do you feel that your relationship and or sex life with your partner is affected by vaginal symptoms?
*
not at all
a little
somewhat
a lot
If so how much does this bother you?
Not at all
1
2
3
4
5
6
7
8
9
A great deal
10
1 is Not at all, 10 is A great deal
How often do you leak urine?
*
Never
once a week or less often
two or three times a week
about once a day
several times a day
all the time
How much urine do you think you usually leak (whether you wear protection or not)?
none
a small amount
a moderate amount
a large amount
Overall, how much does leaking urine interfere with your everyday life?
Not at all
1
2
3
4
5
6
7
8
9
A great deal
10
1 is Not at all, 10 is A great deal
When does urine leak?
never – urine does not leak
leaks before you can get to the toilet
leaks when you cough or sneeze
leaks when you are asleep
leaks when you are physically active/exercising
leaks when you have finished urinating and are dressed
leaks for no obvious reason
leaks all of the time
Submit
Should be Empty: