Pelvic Floor Impact Questionnaire- Short Form 7
(PFIQ)
Patient's Name
*
First Name
Last Name
Today's Date
*
-
Month
-
Day
Year
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)?
Not at all
Somewhat
Moderately
Quite a bit
Not at all
Somewhat
Moderately
Quite a bit
Not at all
Somewhat
Moderately
Quite a bit
Ability to do physical activities such as walking, swimming or other exercise?
Not at all
Somewhat
Moderately
Quite a bit
Not at all
Somewhat
Moderately
Quite a bit
Not at all
Somewhat
Moderately
Quite a bit
Entertainment activities such as going to a movie or concert?
Not at all
Somewhat
Moderately
Quite a bit
Not at all
Somewhat
Moderately
Quite a bit
Not at all
Somewhat
Moderately
Quite a bit
Ability to travel by car or bus for a distance greater than 30 minutes away from home?
Not at all
Somewhat
Moderately
Quite a bit
Not at all
Somewhat
Moderately
Quite a bit
Not at all
Somewhat
Moderately
Quite a bit
Participating in social activities outside your home?
Not at all
Somewhat
Moderately
Quite a bit
Not at all
Somewhat
Moderately
Quite a bit
Not at all
Somewhat
Moderately
Quite a bit
Emotional health (nervousness, depression etc.)?
Not at all
Somewhat
Moderately
Quite a bit
Not at all
Somewhat
Moderately
Quite a bit
Not at all
Somewhat
Moderately
Quite a bit
Feeling frustrated?
Not at all
Somewhat
Moderately
Quite a bit
Not at all
Somewhat
Moderately
Quite a bit
Not at all
Somewhat
Moderately
Quite a bit
Submit
Should be Empty: