Patient Questionnaires


This brief screening tool is to determine a females risk of pelvic floor difficulties. Based on the answers, your provider can better design a safe and effective home program as part of your treatment.

Pelvic Floor Distress Inventory, or PDFI, is a measure of the impact that your pelvic floor conditions have on your quality of life. Quality of life factors include being able to do household tasks, social activities, or things such as driving or walking. This version is a validated shortened version with only 20 questions. 

This form is intended to determine the impact of your pelvic pain condition on six areas of study. This tool is then used by your health care provider to form the best treatment plan that will address these areas. 

You will notice that this form is titled Vulvar Pain Functional Questionnaire (V-Q). We have renamed it here only for the purpose of using it for all genders.

This form is to help determine how your pelvic pain may be impacting your daily activities and mobility. This helps to inform your therapist of what functional activities may be most important to you, or what activities may actually be increasing your pain.

The main purpose of this diary log is to document how your bladder and bowel functions. A log can give your health care provider an excellent picture of your bladder/bowel functions, habits, and patterns. At first, the log is used as an evaluation tool. Later, it will be used to measure your progress on items of retraining or leakage episodes.

This measure was developed by Nelly Faghani from Pelvic Health Solutions in order to determine if your low back and/or hip pain may in fact be due to a pelvic floor condition.

This measure is a screening tool to help determine your beliefs in regards to pain and its consequences on your life.

A brief questionnaire to measure sexual functioning in women and to be used as a diagnostic instrument for improved intervention plans by your provider. It is not a measure of sexual experience, knowledge, attitudes, or interpersonal functioning. 

This measure assesses symptoms and quality of life for females with the condition of chronic prostatitis.

This measure assesses symptoms and quality of life for males with the condition of chronic prostatitis.