Debbie Meyers CNP, MS Maureen Goldman CNP, BCB-PMD 72 Suttle Street, Suite C Durango, CO 81303 Phone (970) 403-8812 Fax (970) 403-8815 Email: sage1hc@gmail.com Website: sagehealthdurango.com Your other muscles in your core include your:Diaphragm: a dome-shaped muscle that helps you breathe with your belly and moves in conjunction with your pelvic floor musclesLumbar Multifidus: little muscles in your back that help stabilize your spine and pelvisTransverse Abdominus: a deep corset-shaped muscle that wraps around our entire abdomen! PELVIC FLOOR SYMPTOM ASSESSMENT INSTRUCTIONS: Considering your symptoms over the last 3 months please answer each question by checking the best response. __yr __mo How many months or years have you had Thank you for your help. Do you now have or have you had a history of the following? Pelvic Organ Prolapse Impact Questionnaire (POPIQ-7): Items under column Pelvis / Vagina Scale Scores: Obtain the mean value for all of the answered items within the Pelvic Floor Impact Questionnaireshort form 7 (PFIQ-7) Author: community Created Date: How many times do you pass urine in the day? Any comments or concerns not addressed in this questionnaire?

NO YES With Debbie Meyers CNP, MS Maureen Goldman CNP, BCB-PMD 88 Magpie Trail Durango, CO 81301 Phone (970) 403-8812 Fax (970) 403-8815 Email: sage1hc@gmail.com Website: sagehealthdurango.com 1. Page 1 of 2 AUSTRALIAN PELVIC FLOOR QUESTIONNAIRE Please circle your most applicable answer. Y N Do you excessively strain to pass stool more than 25% of the time? All information is strictly confidential. PELVIC FLOOR DISTRESS INVENTORY For each question place an X in the response that best describes how much your activities, relationships, or feelings have been Consider your experiences during the last month. How many times to you get up at night to pass urine? The symptoms of pelvic floor dysfunction include:Difficulty urinating or having bowel movementsFeeling like your bowel movements are not completeLeakage of urine or fecesFrequently feeling the need to use the bathroomFeeling like you need to force out urine or fecesStopping and starting in the middle of urinatingLong-term constipationNeeding to change positions to get out a bowel movementMore items

Instructions: The following is a questionnaire about your pelvic health. 1. While answering these questions, please consider your symptoms over the last three months. Pelvic Floor Physical Therapy Questionnaire _____ Patient Name Date Answering the following questions will help us to manage your care better. Pelvic Floor Questionnaire (PFDI) Instructions: Please answer the following question by circling the appropriate number. Consider your exp Patients Name: _____ Date of Birth: _____ Date completed: _____ erience during the last month. Do you experience urine leakage (incontinence) related to physical activity, such as These include:Placing electrodes on the surface of your pelvic area to measure how well the muscles function.Performing an anal manometry to measure how well the anal sphincter is working. Administering a defecating proctogram, a test that includes a thick enema that shows up in an x-ray so your doctor can see how your muscles work to push it out.More items Y N Do you pass hard, small stool? SOWH CAPP - Pelvic Pelvic Floor Therapy Questionnaire Patient name _____ Date _____ Please fill in the following questionnaire to the best of your ability. Please mark (X) in the box that best describes your symptoms in the last month. 0 0 1 1 2 2 3 14155 N. 83rd Ave. BLD 6, Suite 138 Peoria, AZ 85381 Phone: 623-271-8666 Fax: 623-271-9229 www.starclinic.org CONSTIPATION Y N Do you have constipation? female pelvic floor questionnaire name_____ date_____ general medical history please check if you have experienced the following: diabetes sensitivity to cold pacemaker sensitivity to heat high blood pressure allergies bone disease previous surgery chronic headaches seizures These questions will ask you if you have certain bowel, bladder, or pelvic symptoms and, if you do, how much they bother you. If you are unsure about how to answer a question, give the best answer you can. THE AUSTRALIAN PELVIC FLOOR QUESTIONAIRE Please circle your most applicable answer. None Yes. Pelvic Floor Distress Inventory PFDI 20 Patient Name: _____ Date: _____ PFDI- 20 Instructions: Please answer all of the questions in the following survey. We realize that you may not be having problems in some of these areas but please fill out all questions on the form as completely as possible. 0 up to 7 1 between 8 10 2 between 11 15 3 more than 15 2. Y N Do you have less than three bowel movements each week? These techniques can assist women find their pelvic floor muscles:When emptying the bladder try to stop or slow the stream. Imagine you are trying to avoid passing wind in doing so attempt to lift and squeeze the muscles in and around the anus. Use a mirror to view the entrance to your vagina when lying down preferably on your side with a pillow supporting your legs. The therapist will review the answers with you at your appointment. Pelvic Floor Impact Questionnaire Short Form 7 Some women find that bladder, bowel, or vaginal symptoms affect their activities, relationships, and feelings. PELVIC FLOOR PHYSICAL THERAPY QUESTIONNAIRE BLADDER: Was there an event associated with onset of urinary complaints? _____ _____ _____ Questions for female patients only: Gynecological History: Please provide information on any of the following that apply to you: Have you been diagnosed with: Yes No Pelvic Organ Prolapse Endometriosis Cysts Urinary Tract Infections Pelvic Inflammation Disease