Pelvic Health Questionnaire - short form

Welcome to Resolution Physiotherapy & IMS Clinic and thank you for choosing our team of Physiotherapists to help resolve your pain. We look forward to meeting you and showing you how effective our team of highly qualified Physiotherapists can be.

Please complete this questionnaire if our Physiotherapists are treating you for pelvic floor dysfunction.

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* 1. Please type your name. Surname, First Name

Many people leak urine some of the time. We are trying to find out how many people leak urine, and how much this bothers them. We would be grateful if you could answer the following questions, thinking about how you have been, on average, over the PAST FOUR WEEKS.

Please choose the most appropriate answer for the following questions.

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* 2. How often do you leak urine?

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* 3. We would like to know how much urine you think leaks.
How much urine do you usually leak (whether you wear protection or not)?

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* 4. Overall, how much does leaking urine interfere with your everyday life?

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* 5. When does urine leak? (Please select all that apply to you)

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* 6. Interpretation of scores (for office use only)

Total score: (add up scores) = _______        
SCORE RANGE = slight 1-5, moderate 6-12, severe 13-18, very severe 19-21 

ICIQ-UI SF Reference: Avery K, Donovan J, Peters TJ, Shaw C, Gotoh M, Abrams P. ICIQ: a brief and robust measure for evaluating the symptoms and impact of urinary incontinence. Neurourology and Urodynamics: Official Journal of the International Continence Society. 2004;23(4):322-30.