PELVIC FLOOR CENTRE DATA SHEET

Name: ______________________________________________

Date: ___/___/________

Main Complaint: _____________________________________________________________________

Duration of Complaint: _________________________________________________

Please complete the first four pages of this form. If you are unsure of your answer or don’t understand a question, leave it blank and the doctor will assist you.

Bowel Habits and Past History

Please tick the box that best fits your answer:

Do you have or have ever had:
	Arthritis?				yes	no
	Back problems requiring medication or surgery?				yes	no
	Cancer?				yes	no
	Diabetes?				yes	no
	Multiple sclerosis?				yes	no
	Psychiatric illness?				yes	no
	Anal or rectal trauma or pelvic fracture?				yes	no
Describe your usual stools			liquid	formed/soft	pellet	formed/hard
Do you have
	Spasm or pain in the rectum or anus?				yes	no
	Pelvic pain?				yes	no
	Itching around the anus?				yes	no
	Rectal bleeding
(blood you notice in the bowl, on toilet paper or on your clothes)?					yes	no
Do you have a sensation of prolapse
(something coming out or hanging down from the anus or vagina)?					yes	no
	Does the prolapse go in on its own?				yes	no
	Does the prolapse go in when you push on it?				yes	no
	Does the prolapse always stay out?				yes	no
Do you have urinary incontinence
(leakage of urine, urine soiling your clothes, difficulty controlling urine)?					yes	no


Sexual History
Are you sexually active?					yes	no
Do you engage in anal intercourse?					yes	no
Are you able to achieve an orgasm?					yes	no
Do you have pain with intercourse?		not sexually active			yes	no
Male patients: Can you achieve an erection?					yes	no

Incontinence (loss of control)

Do you have incontinence (difficulty controlling your stool or gas, soiling of stool in your clothes, leakage of stool)?

yes - Please tick the box that represents the one best response for each question below.

no – Please go to the next page

In the past 4 weeks, how often did you experience accidental bowel leakage of gas?

	(0)	Never
	(1)	Rarely (once in past 4 weeks)
	(7)	Sometimes (more than once in 4 weeks but less than once a week)
	(13)	Weekly (one or more times a week but not daily)
	(19)	Daily
	(25)	Several times a day

In the past four weeks, how often did you experience minor bowel soiling or seepage?

	(0)	Never
	(31)	Rarely (once in past 4 weeks)
	(37)	Sometimes (more than once in 4 weeks but less than once a week
	(43)	Weekly (one or more times a week but not daily)
	(49)	Daily
	(55)	Several times a day

In the past four weeks, how often did you experience significant accidental bowel leakage of liquid stool?

	(0)	Never
	(61)	Rarely (once in past 4 weeks)
	(73)	Sometimes (more than once in 4 weeks but less than once a week
	(85)	Weekly (one or more times a week but not daily)
	(97)	Daily
	(109)	Several times a day

In the past four weeks, how often did you experience significant accidental bowel leakage of solid stool?

	(0)	Never
	(67)	Rarely (once in past 4 weeks)
	(79)	Sometimes (more than once in 4 weeks but less than once a week
	(91)	Weekly (one or more times a week but not daily)
	(103)	Daily
	(115)	Several times a day

In the past four weeks, how often has this accidental bowel leakage affected your lifestyle?

	(0)	Never
	(1)	Rarely (once in past 4 weeks)
	(2)	Sometimes (more than once in 4 weeks but less than once a week
	(3)	Weekly (one or more times a week but not daily)
	(4)	Daily
	(5)	Several times a day

Constipation

Do you have constipation (hard stools, infrequent stools, difficulty passing stool, incomplete bowel movement?

yes

- please tick the box for the one best response to the following questions:

- please go to the next page

How frequently do you have a bowel movement?

	(1)	More than once a day
	(2)	Daily
	(3)	Every other day
	(4)	About 2-3 times a week
	(5)	About once a week
	(6)	Less often than once a week

How often do you have the feeling of incomplete evacuation?

	(1)	Seldom or never
	(2)	Sometimes
	(3)	Often
	(4)	Very often

Do you have difficult evacuation?

	(4)	Yes, very difficult evacuation
	(3)	Yes, difficult evacuation
	(2)	Sometimes
	(1)	No, evacuation is effortless

Do you have pain during defaecation/straining?

	(1)	No, seldom or never
	(2)	Sometimes
	(3)	Often
	(4)	Nearly always

Do you use your finger or hand to help have a bowel movement?

	Seldom or never
	Sometimes
	Often
	Very often

Do you use the following treatments:

(a) laxatives, enemas or suppositories? (b) fibre supplements?

	More than once a day		More than once a day
	Daily		Daily
	Every other day		Every other day
	About 2-3 times a week		About 2-3 times a week
	About once a week		About once a week
	Less often than once a week		Less often than once a week

In the past four weeks, how often has this constipation affected your lifestyle?

(0)	Never
(1)	Rarely (once in past 4 weeks)
(2)	Sometimes (more than once in 4 weeks but less than once a week
(3)	Weekly (one or more times a week but not daily)
(4)	Daily
(5)	Several times a day

Diarrhoea

Do you have diarrhoea (loose stools, frequent stools, foul smelling stools, urgency)

yes

- please tick the box for the one best response to the following questions:

- thank you. You do not need to fill in any more of the form.

Do you have explosive diarrhoea?

yes

How frequently do you evacuate your bowels during the day?

	1-2 times every 1-2 days
	3-5 times a day
	>6 times a day

How frequently do you evacuate your bowels during the night?

	Once or twice at night
	3-4 times a night
	>5 times a night

Do you have urgency (desire to rush to the toilet for fear of leakage)?

	Never
	Rarely
	Sometimes
	Usually
	Always

In the past four weeks, how often has this diarrhoea affected your lifestyle?

(0)	Never
(1)	Rarely (once in past 4 weeks)
(2)	Sometimes (more than once in 4 weeks but less than once a week
(3)	Weekly (one or more times a week but not daily)
(4)	Daily
(5)	Several times a day

Thank you. You do not need to fill in any more of the form.

Data Sheet Part II (To be completed by Nurse practitioner or Doctor)

Anorectal surgery

Have you ever had anorectal surgery?

yes

	Anorectal abscess surgery
	Fistula-in-ano surgery
	Recto-vaginal fistula surgery
	Fissure surgery
	Haemorrhoid surgery
	Incontinence surgery
	Rectocoele repair
	Prolapse/perineal repair
	Gracilis muscle wrap
	Artificial sphincter

Abdominal surgery

Have you ever had abdominal surgery?

yes

	Bowel resection
	Prolapse – abdominal
	Constipation – bowel resection
	Cholecystectomy

Gynaecological surgery

Have you ever had gynaecological surgery?

yes

	TAHBSO
	TAH
	Vaginal hysterectomy
	Cystocoele repair
	Rectocoele repaired by Gynaecologist
	Salpingo-oophorectomy
	Vaginal prolapse repair
	Other______________________________________________________
	Unknown

Pregnancy

	1	2	3	4	5	6
Delivery #
C-section
Vaginal
Episiotomy
Tear
Forceps/vacuum
Baby weight (lbs oz)	__lbs__oz	__lbs__oz	__lbs__oz	__lbs__oz	__lbs__oz	__lbs__oz

Physical Assessment

not done

done

Visual Inspection

Excoriation			yes	no
Scarring			yes	no
Deformity	marked	moderate	minimal	none
Patulous anus			yes	no
Anal wink			yes	no

Visual Pathology

External Haemorrhoid	present	absent
Internal haemorrhoid	present	absent
Rectal mucosal prolapse	present	absent
Fissure	present	absent
Fistula	present	absent
Other ________________________________________________________________

Digital Exam

Tone			diminished	normal
Squeeze		poor	fair	normal
Palpable defect			yes	no
Anal stenosis	severe	moderate	mild	none
Puborectalis relaxation with strain		paradoxical	equivocal	normal
Rectal prolapse		full thickness	mucosal	none
Cystocoele			yes	not seen
Rectocoele			yes	not seen
Vaginal prolapse			yes	not seen
Enterocoele			yes	not seen
Comments _________________________________________________________________________

Incontinence Score

(Largest number of first three questions plus answer to fourth question): __________

Constipation Score (sum of all answers): __________

(minimum = 4; maximum = 18.

Mean score for spastic pelvic floor = 15

Mean score for defaecation complaints = 8

Mean score for normal = 6)

Nurse/Doctor’s signature __________________________ Date _________________

Investigation Check list

Endoanal/rectal USS	Done	Not done
Transit study	Requested	Done*
Defaecogram	Requested	Done*
Balloon Expulsion test	Done	Not done
Anorectal physiology	Done	Not done
Barium enema	Requested	Done*
Colonoscopy	Requested	Done*
Gynaecology referral	Requested	Done*
Urology referral	Requested	Done*

*Secretaries will tick the done box as and when the relevant investigations are done and results are checked by the consultants. When all the investigations or referral are done, a second appointment is scheduled by the secretaries.

Physiology Data collection form

USS rectum – report

USS Anal canal – report

PNMTL –

Left
Right

Resting Anal Canal pressure (cms water) –

Functional anal canal length (cms) –

Maximum squeeze pressure (cms) –

Cough response – Rectal pressure (cms) –

Anal canal pressure (cms) –

Valsalva manouvre – Rectal pressure (cms) –

Anal canal pressure (cms) –

RAIR – Sudden distention Present Absent

Balloon expulsion test - Unable to expel Able to expel

Rectal sensation

Mode of testing Rapid distention Ramp inflation (60 ml/min)

Parameter

MTT

Volume (ml)

Pressure (cm)

Uncorrected

Report –

Action –

Surgery	yes	no
Pelvic floor PT	yes	no
Biofeedback	yes	no
Sphincter stimulation	yes	no
Psychotherapy	yes	no
Discharged	yes	no

Other actions/details of surgery planned

Patient Satisfaction Questionnaire:- (all patients to complete this on every visit. Nurse practitioner to ensure they have received this.

Dear Patient,

East Kent Pelvic floor services is committed to patient-centred care in the area of anorectal dysfunction. Your response to our survey will assist us in determining how well we are doing and how we can improve our services. Thank you for your comments and suggestions. It has been our pleasure serving your health needs.

Yours sincerely,

Mr.G.Nagesh.Rao

Consultant Colorectal Surgeon

DATE AND TIME OF VISIT: ___________________________________________

Please tick the appropriate boxes.

	Strongly disagree	Disagree	Somewhat agree	Agree	Strongly agree
I found the check in process efficient
I received pre-procedural explanation that was understandable and complete for the test/tests I was having
I found the department to be clean
I found the department to be private
I was treated in a professional and caring manner by all of the health care staff.
Post-procedure instructions were given to me at discharge

Please provide comments or details regarding your concerns or observations of your visit to the Pelvic floor centre.

Did you experience any complications or physical problems following your procedure or test? yes no

If yes, please describe symptoms and how long they lasted: _____________________

Please provide your name and phone number if you would like someone to contact you to further discuss this survey or provide additional information:

Name: ___________________________Phone number: ____________