Pelvic Floor Inpact Questionnaire Short Form 7

Some women find that bladder, bowel, or vaginal symtoms affect their activities, relationships, and feelings. For each question place an X in the response that best describes how much your activities, relationships, or feelings have been affected by your bladder, bowel, or vaginal symtoms or conditions over the last 3 months. Please make sure you mark an answer in all 3 columns for each question.


How do symtoms or conditions relate to the following usually affect your ability to do household chores (cooking housecleaning, laundry)?

Bladder or urine

Not at all
Somewhat
Moderately
Quite a bit

Bowel or rectum

Not at all
Somewhat
Moderately
Quite a bit

Vagina or pelvis

Not at all
Somewhat
Moderately
Quite a bit

How do symtoms or conditions relate to the following usually affect your ability to do phisycal activities such as walking, swimming, or other exercise?

Bladder or urine

Not at all
Somewhat
Moderately
Quite a bit

Bowel or rectum

Not at all
Somewhat
Moderately
Quite a bit

Vagina or pelvis

Not at all
Somewhat
Moderately
Quite a bit

How do symtoms or conditions relate to the following usually affect your entertainment activitie such as going to a movie or concert?

Bladder or urine

Not at all
Somewhat
Moderately
Quite a bit

Bowel or rectum

Not at all
Somewhat
Moderately
Quite a bit

Vagina or pelvis

Not at all
Somewhat
Moderately
Quite a bit

How do symtoms or conditions relate to the following usually affect your ability to travel by car or bus for a distance greater than 30 minutes away from home?

Bladder or urine

Not at all
Somewhat
Moderately
Quite a bit

Bowel or rectum

Not at all
Somewhat
Moderately
Quite a bit

Vagina or pelvis

Not at all
Somewhat
Moderately
Quite a bit

How do symtoms or conditions relate to the following usually affect your participating in social activities outsite your home?

Bladder or urine

Not at all
Somewhat
Moderately
Quite a bit

Bowel or rectum

Not at all
Somewhat
Moderately
Quite a bit

Vagina or pelvis

Not at all
Somewhat
Moderately
Quite a bit

How do symtoms or conditions relate to the following usually affect your emotional health(nervousness, depression, etc) ?

Bladder or urine

Not at all
Somewhat
Moderately
Quite a bit

Bowel or rectum

Not at all
Somewhat
Moderately
Quite a bit

Vagina or pelvis

Not at all
Somewhat
Moderately
Quite a bit

How do symtoms or conditions relate to the following usually affect your feeling frustrated?

Bladder or urine

Not at all
Somewhat
Moderately
Quite a bit

Bowel or rectum

Not at all
Somewhat
Moderately
Quite a bit

Vagina or pelvis

Not at all
Somewhat
Moderately
Quite a bit

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