Scribd
Upload
192 views2 pages

PFDI

This document appears to be a pelvic floor distress inventory questionnaire for a patient named Kathy Y. Jones. The questionnaire contains 20 yes or no questions about symptoms related to bowel, bladder, and pelvic functioning over the last 6 months. For each symptom experienced, the patient is asked to rate how much the symptom bothers them on a scale of not at all, somewhat, moderately, or quite a bit. The questionnaire will be used to assess symptoms of pelvic floor dysfunction.

Uploaded by

misbah_md
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
192 views2 pages

PFDI

This document appears to be a pelvic floor distress inventory questionnaire for a patient named Kathy Y. Jones. The questionnaire contains 20 yes or no questions about symptoms related to bowel, bladder, and pelvic functioning over the last 6 months. For each symptom experienced, the patient is asked to rate how much the symptom bothers them on a scale of not at all, somewhat, moderately, or quite a bit. The questionnaire will be used to assess symptoms of pelvic floor dysfunction.

Uploaded by

misbah_md
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
You are on page 1/ 2

Patient Name: Date:

PFDI- SF20 1 Kathy Y. Jones, MD


If ye s , how much does it bother you?
Not at all Somewhat Moderately Quite a bit
Do you usually experience pressure in the lower abdomen?
YES N
Do you usually experience hea!iness or dullness in the lower
abdomen?
YES N
Do you usually ha!e a bul"e or somethin" #allin" out that you
can see or #ell in the !a"inal area?
YES N
Do you usually ha!e to push on the !a"ina or around the
rectum to ha!e a complete bowel mo!ement?
YES N
Do you usually experience a #eelin" o# incomplete bladder
emptyin"?
YES N
Do you e!er ha!e to push up in the !a"inal area with your
#in"ers to start or complete urination?
YES N
Do you #eel you need to strain too hard to ha!e a bowel
mo!ement?
YES N
Do you #eel you ha!e not completely emptied your bowels at
the end o# a bowel mo!ement?
YES N
Do you usually lose stool beyond your control i# your stool is
well #ormed?
YES N
Pelvic Floor Distress Inventory Questionnaire - Short Form 20
Please answer all o# the $uestions in the #ollowin" sur!ey% &hese $uestions will as' you i# you ha!e certain bowel, bladder or pel!ic symptoms
and i# you do how much they bother you% (nswer each $uestion by puttin" an in the appropriate box or boxes% )# you are unsure about how
to
answer, please "i!e the best answer you can% *hile answerin" these $uestions, please consider your symptoms o!er the last ! months"
#
2
!
$
%
&
'
(
)
If yes, how much does it bother you?
Not at all Somewhat Moderately Quite a bit
Do you usually lose stool beyond your control i# you stool is
loose or li$uid?
YES N
Do you usually lose "as #rom the rectum beyond your
control?
YES N
Do you usually ha!e pain when you pass your stool?
YES N
Do you experience a stron" sense o# ur"ency and ha!e to
rush to the bathroom to ha!e a bowel mo!ement?
YES N
Does part o# your stool e!er pass throu"h the rectum and
bul"e outside durin" or a#ter a bowel mo!ement?
YES N
D you usually experience #re$uent urination
YES N
Do you usually experience urine lea'a"e associated with a
#eelin" o# ur"ency+ that is, a stron" sensation o# needin" to
"o to the bathroom?
YES N
Do you usually experience urine lea'a"e related to lau"hin",
cou"hin", or snee,in"-
YES N
Do you usually experience small amounts o# urine lea'a"e
.that is, drops/?
YES N
Do you usually experience di##iculty emptyin" your bladder?
YES N
Do you usually experience pain o# discom#ort in the lower
abdomen or "enital re"ion?
YES N
PFDI- SF20 0 Kathy Y. Jones, MD
Patient Name: Date:
#0
##
#2
#!
#$
#%
#&
#'
#(
#)
20

You might also like