Pelvic Floor Function Survey (PFDI-20)
Please answer all of the questions in the following survey. These questions will ask you if you have certain bowel, bladder, or pelvic symptoms and, if you do, how much they bother you. 

Answer these by selecting the appropriate number. While answering these questions, please consider your symptoms over the last 3 months. The PFDI-20 has 20 items and 3 scales of your symptoms. All items use the following format with a response scale from 0 to 4.
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Email *
Name (First and Last) *
Phone Number *
Scale
0 = not present, NO this never happens to me
1=  yes this happens to me, but it DOES NOT BOTHER me at all
2 = bothers me SOMEWHAT
3 = bothers me MODERATELY
4 = bothers me QUITE A BIT
Do you....
 Usually experience pressure in the lower abdomen? *
No this doesn't happen to me
Yes this happens to me- It bothers me quite a bit
Usually experience heaviness or dullness in the pelvic area? *
No this doesn't happen to me
Yes this happens to me- It bothers me quite a bit
Usually have a bulge or something falling out that you can see or feel in your vaginal area? *
No this doesn't happen to me
Yes this happens to me- It bothers me quite a bit
Ever have to push on the vagina or around the rectum to have or complete a bowel movement? *
No this doesn't happen to me
Yes this happens to me- It bothers me quite a bit
Usually experience a feeling of incomplete bladder emptying? *
No this doesn't happen to me
Yes this happens to me- It bothers me quite a bit
Ever have to push up on a bulge in the vaginal area with your fingers to start or complete urination? *
No this doesn't happen to me
Yes this happens to me- It bothers me quite a bit
Do you...
Feel you need to strain too hard to have a bowel movement? *
No this doesn't happen to me
Yes this happens to me- It bothers me quite a bit
Feel you have not completely emptied your bowels at the end of a bowel movement? *
No this doesn't happen to me
Yes this happens to me- It bothers me quite a bit
Usually lose stool beyond your control if your stool is well formed? *
No this doesn't happen to me
Yes this happens to me- It bothers me quite a bit
Usually lose stool beyond your control if your stool is loose? *
No this doesn't happen to me
Yes this happens to me- It bothers me quite a bit
Usually lose gas from the rectum beyond your control? *
No this doesn't happen to me
Yes this happens to me- It bothers me quite a bit
Usually have pain when you pass your stool? *
No this doesn't happen to me
Yes this happens to me- It bothers me quite a bit
Experience a strong sense of urgency and have to rush to the bathroom to have a bowel movement? *
No this doesn't happen to me
Yes this happens to me- It bothers me quite a bit
Does part of your bowel ever pass through the rectum and bulge outside during or after a bowel movement? *
No this doesn't happen to me
Yes this happens to me- It bothers me quite a bit
Do you...
Usually experience frequent urination? *
No this doesn't happen to me
Yes this happens to me- It bothers me quite a bit
Usually experience urine leakage associated with a feeling of urgency, that is, a strong sensation of needing to go to the bathroom? *
No this doesn't happen to me
Yes this happens to me- It bothers me quite a bit
Usually experience urine leakage related to coughing, sneezing or laughing? *
No this doesn't happen to me
Yes this happens to me- It bothers me quite a bit
Usually experience small amounts of urine leakage (that is, drops)? *
No this doesn't happen to me
Yes this happens to me- It bothers me quite a bit
Usually experience difficulty emptying your bladder? *
No this doesn't happen to me
Yes this happens to me- It bothers me quite a bit
Usually experience pain or discomfort in the lower abdomen or genital region? *
No this doesn't happen to me
Yes this happens to me- It bothers me quite a bit
A copy of your responses will be emailed to the address you provided.
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