URINARY PROBLEMS The following questions are about going to the toilet for a wee. This is also called voiding. Some women sometimes feel a sudden, overwhelming need to go to the toilet. This is called urgency. For each of the following questions, please circle the answer that best describes how you feel. 0 1 2 3 4 1 How many times do you void (go 3-6 7-10 11-14 15-19 20+ for a wee) during waking hours? 2a How many times do you void at 0 1 2 3 4+ night? 2b If you get up at night, to what Never Mildly Severe extent does it usually bother you? 3 Are you currently sexually active? Yes No 4a IF YOU ARE SEXUALLY ACTIVE, Never Occasionally Usually Always do you now, or have you ever had, pain or urgency to urinate during or after sexual intercourse? Never Occasionally Usually Always 4b Has the pain or urgency ever made you avoid sexual intercourse? 5 Do you have pain associated with Never Occasionally Usually Always your bladder or in your pelvis, vagina, lower abdomen, urethra (the opening from which you wee) or perineum (the area between your front and back passage)? Never Occasionally Usually Always 6 Do you still have urgency shortly after urinating? Mild Moderate Severe 7a When you have pain, is it usually? Never Occasionally Usually Always 7b How often does this pain bother you? Mild Moderate Severe 8a When you have urgency, it is usually? Never Occasionally Usually Always 8b How often does this bother you? Parsons C.L. J Reprod Med 2004;49(Supplement 3):235-42. Yes No Do you suffer from pain when your bladder is filling?
URINARY PROBLEMS The following questions are about going to the toilet for a wee. This is also called voiding. Some women sometimes feel a sudden, overwhelming need to go to the toilet. This is called urgency. For each of the following questions, please circle the answer that best describes how you feel. 0 1 2 3 4 1 How many times do you void (go for a wee) during waking hours? 3-6 7-10 11-14 15-19 20+ 2a How many times do you void at night? 0 1 2 3 4+ 2b If you get up at night, to what extent does it usually bother you? Never Mildly Severe 3 Are you currently sexually active? Yes No 4a IF YOU ARE SEXUALLY ACTIVE, do you now, or have you ever had, pain or urgency to urinate during or after sexual intercourse? Never Occasionally Usually Always 4b Has the pain or urgency ever made you avoid sexual intercourse? Never Occasionally Usually Always 5 Do you have pain associated with your bladder or in your pelvis, vagina, lower abdomen, urethra (the opening from which you wee) or perineum (the area between your front and back passage)? Never Occasionally Usually Always 6 Do you still have urgency shortly after urinating? Never Occasionally Usually Always 7a When you have pain, is it usually? Mild Moderate Severe 7b How often does this pain bother you? Never Occasionally Usually Always 8a When you have urgency, it is usually? Mild Moderate Severe 8b How often does this bother you? Never Occasionally Usually Always Parsons C.L. J Reprod Med 2004;49(Supplement 3):235-42. Yes No Do you suffer from pain when your bladder is filling?
Form-02(b)-Medal-Pelvic-Pain-Assessment-Questionnaire)-(Patient-re-entry-Form)-V21-27-11-2012.docx