The Pelvic Pain Impact Questionnaire

The Pelvic Pain Impact Questionnaire

First Name *

Middle Name

Surname *

Date of Birth *

Email address *

Phone Number *

Date *

Directions:

For each of the following 8 questions, tick the box that best indicates how much your pelvic pain has affected these aspects of your life during the past month. Your answers to these questions can then be summed to give you a final score.

In the past month, how much has your pelvic pain affected your:

Not at all (0)A little bit (1)Somewhat (2)Quite a bit (3)A great deal (4)

energy levels?

Not at all (0)A little bit (1)Somewhat (2)Quite a bit (3)A great deal (4)

mood?

Not at all (0)A little bit (1)Somewhat (2)Quite a bit (3)A great deal (4)

sleep?

Not at all (0)A little bit (1)Somewhat (2)Quite a bit (3)A great deal (4)

stomach and intestinal function?

Not at all (0)A little bit (1)Somewhat (2)Quite a bit (3)A great deal (4)

ability to sit for longer than 20 minutes? ability to perform and function normally at

Not at all (0)A little bit (1)Somewhat (2)Quite a bit (3)A great deal (4)

home/work/school/university?

Not at all (0)A little bit (1)Somewhat (2)Quite a bit (3)A great deal (4)

ability to take part in physical activity? (e.g. jogging, yoga, bicycling)

Not at all (0)A little bit (1)Somewhat (2)Quite a bit (3)A great deal (4)

ability to wear certain clothes? (e.g. underwear, tight fitting clothes)

Not at all (0)A little bit (1)Somewhat (2)Quite a bit (3)A great deal (4)

If the following questions apply to you, please answer. If not, please leave these blank. These questions will not be added to your summed score.

Not at all (0)A little bit (1)Somewhat (2)Quite a bit (3)A great deal (4)

During your last period, how much did your pelvic pain affect your ability to use tampons?

Not at all (0)A little bit (1)Somewhat (2)Quite a bit (3)A great deal (4)

In the past month, how much has your pelvic pain affected your levels of intimacy or sexual relationships? (e.g. having sex, masturbating)

Not at all (0)A little bit (1)Somewhat (2)Quite a bit (3)A great deal (4)

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