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)