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3PSQ - Pelvic Pain Psychological Screening Questionnaire
Incontinence Questionnaire
1.
Please type your name. Surname, First Name
Everyone experiences painful situations at some point in their lives.
We are interested in the thoughts and feelings that you have when you experience pelvic pain and how you cope with it.
*
2.
In the past month:
(Required.)
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
I feel overly stressed
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
I felt nervous, anxious or on edge
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
I worried a lot about my health
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
I felt down, depressed or hopeless
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
I took little interest or pleasure in doing
things
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
I worried whether something serious was
wrong
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
*
3.
In the past month:
(Required.)
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
I couldn’t seem to keep the pain out of my
mind
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
I paid close attention to my pain
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
I could not confidently live a normal lifestyle
due to my pain
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
I felt helpless in being able to reduce or cope
with the pain
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
I was afraid of the pain
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
I tried to avoid anything that caused or
worsened my pain
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
*
4.
During my life:
(Required.)
0 No
4 Yes
I have had a stressful experience or traumatic life event that has had a negative impact on me
0 No
4 Yes
*
5.
If you have been sexually active in the past month, please answer the following:
(Required.)
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
I avoided sexual activity because of my pain
0 Never
1 Rarely
2 Sometimes
3 Often
4 Always
*
6.
If you have been sexually active in the past month, please answer the following:
(Required.)
4 Never
3 Rarely
2 Sometimes
1 Often
0 Always
I could say no to sexual activity if I didn’t want it
4 Never
3 Rarely
2 Sometimes
1 Often
0 Always
7.
Interpretation of scores (for office use only)
TOTAL
score: (add up scores) = _________
SCORE range: 0 (no Impact) - 60 (highest Impact)
