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PGQ - Pelvic Girdle Questionnaire
Pelvic Pain Questionnaire
1.
Please type your name. Surname, First Name
To what extent do you find it problematic to carry out the activities listed below because of pelvic
girdle pain?
For each activity check ( √ ) the box that best describes how you are today.
*
2.
How problematic is it for you
because of your pelvic girdle
pain to:
(Required.)
0 not at all
1 to a small extent
2 to some extent
3 to a large extent
Dress yourself
0 not at all
1 to a small extent
2 to some extent
3 to a large extent
Stand for less than 10 minutes
0 not at all
1 to a small extent
2 to some extent
3 to a large extent
Stand for more than 60 minutes
0 not at all
1 to a small extent
2 to some extent
3 to a large extent
Bend down
0 not at all
1 to a small extent
2 to some extent
3 to a large extent
Sit for less than 10 minutes
0 not at all
1 to a small extent
2 to some extent
3 to a large extent
Sit for more than 60 minutes
0 not at all
1 to a small extent
2 to some extent
3 to a large extent
Walk for less than 10 minutes
0 not at all
1 to a small extent
2 to some extent
3 to a large extent
Walk for more than 60 minutes
0 not at all
1 to a small extent
2 to some extent
3 to a large extent
Climb stairs
0 not at all
1 to a small extent
2 to some extent
3 to a large extent
Do housework
0 not at all
1 to a small extent
2 to some extent
3 to a large extent
*
3.
How problematic is it for you because of your pelvic girdle pain to:
(Required.)
0 not at all
1 to a small extent
2 to some extent
3 to a large extent
Carry light objects
0 not at all
1 to a small extent
2 to some extent
3 to a large extent
Carry heavy objects
0 not at all
1 to a small extent
2 to some extent
3 to a large extent
Get up/sit down
0 not at all
1 to a small extent
2 to some extent
3 to a large extent
Push a shopping cart
0 not at all
1 to a small extent
2 to some extent
3 to a large extent
Run
0 not at all
1 to a small extent
2 to some extent
3 to a large extent
Carry out sporting activities (leave blank if N/A)
0 not at all
1 to a small extent
2 to some extent
3 to a large extent
Lie down
0 not at all
1 to a small extent
2 to some extent
3 to a large extent
Roll over in bed
0 not at all
1 to a small extent
2 to some extent
3 to a large extent
Have a normal sex life (leave blank if N/A)
0 not at all
1 to a small extent
2 to some extent
3 to a large extent
Push something with one foot
0 not at all
1 to a small extent
2 to some extent
3 to a large extent
*
4.
How much pain do you experience:
(Required.)
0 none
1 some
2 moderate
3 considerable
In the morning
0 none
1 some
2 moderate
3 considerable
In the evening
0 none
1 some
2 moderate
3 considerable
*
5.
To what extent because of pelvic girdle pain:
(Required.)
0 not at all
1 to a small extent
2 to some extent
3 to a large extent
Has your leg/have
your legs given way
0 not at all
1 to a small extent
2 to some extent
3 to a large extent
Do you do things
more slowly
0 not at all
1 to a small extent
2 to some extent
3 to a large extent
Is your sleep
interrupted
0 not at all
1 to a small extent
2 to some extent
3 to a large extent
6.
Interpretation of scores (for office use only)
TOTAL % Disability
score: (add up scores________/75)x100 = __________
*note if no response for sex or sport question, reduce to divide by 75-3 for each answer not given*
SCORE range: 0 (no disability) - 100 (highest disability)
Reference: Stuge B, Garratt A, Jenssen H, Grotle M. The Pelvic Girdle Questionnaire: A Condition Specific Instrument for Assessing Activity Limitations and Symptoms in People with Pelvic Girdle Pain. Physical Therapy. July 2011; 91(7): 10961108.
