Patient Questionnaires

Bowel, Bladder or Pelvic Symptoms

These two questionnaires will ask you if you have certain bowel, bladder, or pelvic symptoms and, if you do, how much they bother you. Please fill out both tests if you have abdominal, vulvar, pelvic and/or rectal pain with intercourse, with use of a tampon, with getting a pelvic exam at your gynecologist’s office; with urinating or having a bowel movement or with sitting.

Impact to Activities, Relationships and Feelings

Some women find that bladder, bowel, or vaginal symptoms affect their activities, relationships, and feelings. For each question place an “X” in the 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 3 months.

Low Back, Sacral or Coccyx Pain

Last year I woke up one morning and thought that I must be developing a bladder infection. I constantly felt like I had to pee and over the next few days the sensation built and nothing would make it stop. Two urine tests were negative for infection and my symptoms grew worse. In a short period of t…

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