Pelvic Floor Questionnaire

Pelvic Floor Questionnaire

BLADDER QUESTIONS
Do you need to rush to get to the toilet on time? YES NO
Do you leak when you cough, sneeze, laugh and/or exercise? YES NO
Do you limit your fluid intake during the day so that you don’t go to the toilet as often? YES NO
Have you noticed an increase in the number of times you need to empty your bladder? YES NO
Can you delay the urge to empty your bladder? YES NO
BOWEL QUESTIONS
Do you pass wind without being able to control it? YES NO
Do you need to wipe lots to clean after emptying your bowels? YES NO
Are your underpants stained from stool despite having gone to the toilet? YES NO
Do you strain when you are on the toilet? YES NO
Have you ever suffered from constipation? YES NO

*Questions based on those included in “The Australian Pelvic Floor Questionnaire” developed by Baessler, O’Neill, Maher & Battistutta and published in 2010.