Pelvic Floor Symptom Assessment
Patient Details
Name
*
First Name
Last Name
Age
*
Date
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Urinary Function Impact Scores
Rate the below question on a scale from 0-3
To what extent does your urinary function problem affect your daily tasks - cleaning, shopping?
*
Not at all
0
1
2
Severe
3
0 is Not at all, 3 is Severe
To what extent does your urinary function problem affect your tasks outside of the home - shopping, working, social outings etc.?
*
Not at all
0
1
2
Severe
3
0 is Not at all, 3 is Severe
To what extent does your urinary function problem affect your physical activity - walking, running, sport, going to the gym etc.?
*
Not at all
0
1
2
Severe
3
0 is Not at all, 3 is Severe
To what extent does your urinary function problem affect your ability to travel?
*
Not at all
0
1
2
Severe
3
0 is Not at all, 3 is Severe
To what extent does your urinary function problem affect your relationship with your partner?
*
Not at all
0
1
2
Severe
3
0 is Not at all, 3 is Severe
To what extent does your urinary function problem affect your sex life?
*
Not at all
0
1
2
Severe
3
0 is Not at all, 3 is Severe
To what extent does your urinary function problem affect your mood e.g. anxiety or depression?
*
Not at all
0
1
2
Severe
3
0 is Not at all, 3 is Severe
To what extent does your urinary function problem cause you self esteem issues e.g. embarrassment due to incontinence, concern re smell or other?
*
Not at all
0
1
2
Severe
3
0 is Not at all, 3 is Severe
To what extent does your urinary function problem affect your daily activities due to managing incontinence - pad changes, changing clothes, washing etc.?
*
Not at all
0
1
2
Severe
3
0 is Not at all, 3 is Severe
Number of pad changes per day
Number of clothes changes per day
To what extent does your urinary function problem affect your sleep?
*
Not at all
0
1
2
Severe
3
0 is Not at all, 3 is Severe
Average times you pass urine overnight
Overall, how much does your urinary function problem bother you?
*
Not at all
0
1
2
Severe
3
0 is Not at all, 3 is Severe
Total Score
Submit
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