Victoria, BC

Victoria Gynecology & Continence Clinic

Pelvic Floor Questionnaire

Our goal is to provide you with the best service possible. Please complete this questionnaire to help us assist you.

*Please note that unless encrypted, email messages sent via the internet may not be secure and could be intercepted and read by someone else. Please bear this in mind when deciding whether to include personal or sensitive information in any email messages you intend to send. The office of Dr. David Quinlan accepts no responsibility for any information submitted that fails to reach its intended recipient.

If you would prefer to print the form and return it to our office in person, you can download it here: Pelvic Floor Questionnaire

Bladder Section:

How many times do you pass urine in a day?

 

How many times do you get up in the night to pass urine?

 

Do you wet the bed before you wake up?

 

Do you need to rush/hurry to pass urine when you get the urge?

 

Does urine leak when you rush/hurry to the toilet or can't make it in time?

 

Do you leak when coughing, sneezing, laughing or exercising?

 

Is your urinary stream (urine flow) weak, prolonged or slow?

 

Do you have a feeling of incomplete bladder emptying?

 

Do you need to strain to empty your bladder?

 

Do you have to wear a pad because of urinary leakage?

 

Do you limit your fluid intake to decrease urinary leakage?

 

Do you have frequent bladder infections?

 

Do you have pain in your bladder or urethra when you empty your bladder?

 

Does urine leakage affect your routine activities like recreation, socializing, sleeping, shopping etc.?

 

How much of a bother is your bladder problem to you?

 

Bowel Section:

How often do you usually empty your bowels?

 

How is the consistency of your usual stool?

 

Do you have to strain a lot to empty your bowels?

 

Do you use laxatives to empty your bowels?

 

Do you feel constipated?

 

When you get wind or flatus, can you control it or does wind leak?

 

Do you get an overwhelming sense of urgency to empty your bowels?

 

Do you leak watery stool when you don't mean to?

 

Do you leak normal stool when you don't mean to?

 

Do you have a feeling of incomplete bowel emptying?

 

Do you have to use finger pressure to help empty your bowels?

 

How much does your bowel problem bother you?

 

Prolapse Symptoms:

Do you have a sensation of tissue protrusion or a lump or a bulging in your vagina?

 

Do you experience vaginal pressure or heaviness or a dragging sensation?

 

Do you have to push back your prolapse in order to void?

 

Do you have to push back your prolapse in order to empty your bowels?

 

How much does your prolapse bother you?

 

Sexual Function Section:

Are you sexually active?

 

If not sexually active, please answer questions 34 and 42 only.

If you are not sexually active, please tell us why.

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Do you have sufficient natural lubrication during intercourse?

 

During intercourse vaginal sensation is:

 

Do you feel that your vagina is too loose or lax?

 

Do you feel that your vagina is too tight?

 

Do you experience pain with sexual intercourse?

 

Where does the pain occur?

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Do you leak urine during sexual intercourse?

 

How much of a bother are these sexual issues to you?

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If you would like a copy of your completed form, please click the "Print Page" button below before you click the "Submit Form" button.

*Please note that unless encrypted, email messages sent via the internet may not be secure and could be intercepted and read by someone else. Please bear this in mind when deciding whether to include personal or sensitive information in any email messages you intend to send. The office of Dr. David Quinlan accepts no responsibility for any information submitted that fails to reach its intended recipient.