Initial Pelvic Floor Physiotherapy

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Date of birth

Please list the three key goals you would like to address from this consultation:
1.
2.
3.

Do you have a latex allergy?
---YesNo
Do you have any other allergies?
---YesNo
If YES, please list blow:

THE AUSTRALIAN PELVIC FLOOR QUESTIONNAIRE
Please select your most applicable answer. Consider your experiences during the last month.

BLADDER FUNCTION
1. How many times do you pass urine in the day?
---up to 7between 8-10between 11-15more than 15
2. How many times do you get up night to pass urine?
---0 – 123More than 3 times
3. Do you wet the bed before you wake up at night?
---NeverOccasionally – less than once a weekFrequently - once or more than per weekAlways - every night
4. Do you need to rush or hurry to pass urine when you get the urge?
---Never – can hold onOccasionally – less than once per weekFrequently – more than once per weekDaily
5. Does urine leak when you rush or hurry to the toilet. Can you make it in time?
---Not at allOccasionally – less than once per weekFrequently – once or more per weekDaily
6. Do you leak with coughing, sneezing, laughing or exercising?
---Not at allOccasionally – less than once a weekFrequently - once or more than per weekDaily
7. Is your urinary stream (urine flow) weak, prolonged or slow?
---NeverOccasionally – less than once per weekFrequently – more than once per weekDaily
8. Do you have a feeling of incomplete bladder emptying?
---NeverOccasionally – less than once per weekFrequently – once or more per weekDaily
9. Do you feel you need to strain to empty your bladder?
---NeverOccasionally – less than once a weekFrequently - once or more than per weekAlways - every night
10. Do you have to wear pads because of urinary leakage?
---None - neverAs a precautionWhen exercising or during a coldDaily
11. Do you limit your fluid intake to decrease leakage?
---NeverBefore going outModeratelyAlways
12. Do you have frequent bladder infections?
---No1 – 3 per year4 – 12 per yearMore than one per month
13. Do you have pain in your bladder or urethra when you empty your
bladder?
---NeverOccasionally – less than once per weekFrequently – more than once per weekDaily
14. Does urine leakage affect your daily routine activities like recreation, socialising, sleeping, shopping etc?
---Not at allSlightlyModeratelyGreatly
15. How much does your bladder problem bother you?
---Not at allSlightlyModeratelyGreatly
Other symptoms:

BOWEL FUNCTION
16. How often do you usually you’re your bowels?
---Every other day or dailyLess than every 3 daysLess than once a weekMore than once a day
17. How is the consistency of your usual stool?
---SoftFirmHard (pebbles)VariableWatery
18. Do you have to strain a lot to empty your bowels?
---NeverOccasionally – less than once a weekFrequently - once or more than once per weekDaily
19. Do you use laxatives to empty your bowels?
---NeverOccasionally – less than once per weekFrequently – once or more than once per weekDaily
20. Do you feel constipated?
---NeverOccasionally – less than once per weekFrequently – once or more than once per weekDaily
21. When you get wind or flatus, does wind leak?
---NeverOccasionally – less than once a weekFrequently - once or more than once per weekDaily
22. Do you get an overwhelming sense of urgency to empty your bowels?
---NeverOccasionally – less than once per weekFrequently – more than once per weekDaily
23. Do you leak watery stool when you don’t meant to?
---NeverOccasionally – less than once per weekFrequently – once or more per weekDaily
24. Do you leak normal stool when you don’t mean to?
---NeverOccasionally – less than once a weekFrequently - once or more than per weekAlways - every night
25. Do you have a feeling of incomplete bowel empyting?
---NeverOccasionally – less than once a weekFrequently – once or more than once a weekDaily
26. Do you use finger pressure to empty your bowel?
---NeverOccasionally –less than once a weekFrequently – once or more than once a weekDaily
27. How much does your bowel problem bother you?
---Not at allSlightlyModeratelyGreatly

MALE NIH - Chronic Prostatitis Symptom Index (NIH-CPSI)
If pain is not an issue, you do not need to complete the remaining questions. Please click "send" now.
PAIN OR DISCOMFORT
1. In the last week, have you experienced any pain or discomfort in the following areas:
a. Area between rectum and testicles(perineum)
---YesNo
b. Testicles
---YesNo
c. Tip of the penis (not related to urination)
---YesNo
d. Below your waist, in your pubic or bladder area
---YesNo
2. In the last week, have you experienced:
a. Pain or burning during urination
---YesNo
b. Pain or discomfort during or after sexual climax (ejaculation)
---YesNo
3. How often have you had pain or discomfort in any of these areas over the last week?
---NeverRarelySometimesOftenUsuallyAlways
4. Which number best describes your AVERAGE pain or discomfort on the days that you had it, over the last week?
---0 = No pain12345678910 - Pain as bad as you can imagine

URINATION
5. How often have you had a sensation of not emptying your bladder completely after you finished urinating over the last week?
---Not at allLess than 1 time in 5Less than half the timeAbout half the timeMore than half the timeAlmost always
6. How often have you had to urinate again less than two hours after you finished urinating, over the last week?
---Not at allLess than 1 time in 5Less than half the timeAbout half the timeMore than half the timeAlmost always

IMPACT OF SYMPTOMS
7. How much have your symptoms kept you from doing the kinds of things you would usually do, over the last week?
---NoneOnly a littleSomeA lot
8. How much did you think about your symptoms, over the last week?
---NoneOnly a littleSomeA lot

QUALITY OF LIFE
9. If you were to spend the rest of your life with your symptoms just the way they have been during the last week, how would you feel about that?
---DelightedPleasedMostly satisfiedMixed (about equally satisfied and dissatisfied)Mostly dissatisfiedUnhappyTerrible

We respect the privacy of our patients and any information provided remains confidential.