Pelvic Floor Impact Questionnaire- Short Form 7

Pelvic Floor Impact Questionnaire- Short Form 7

(PFIQ)
Patient's Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
Instructions:

Some women find that bladder, bowel or vaginal symptoms affect their activities, relationships and feelings. For each question select a 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 three months.

How do symptoms or conditions relate to the following... usually affect your...*

	Bladder or Urine	Bowel or Rectum	Vagina or Pelvis
Ability to do household chores (cooking, housecleaning, laundry)?
Ability to do physical activities such as walking, swimming or other exercise?
Entertainment activities such as going to a movie or concert?
Ability to travel by car or bus for a distance greater than 30 minutes away from home?
Participating in social activities outside your home?
Emotional health (nervousness, depression etc.)?
Feeling frustrated?

Instructions: