FEMALE NIH-CPSI

    Pain or Discomfort

    1. In the last week, have you experienced any pain or discomfort in the following areas?





    2. In the last week, have youexperienced:


    3. How often have you had pain or discomfort in any of these areas over the last week?







    4. Which number best describes your AVERAGE pain or discomfort on the days that you had it, over the last week?











    Urination

    5. How often have you had a sensation of not emptying your bladder completely after you finished urinating, over the last week?






    6. How often have you had to Urinate again less than two hours after you finishded Urinating.over the last week?






    Imoact of $ymotoms

    7. Now much have your symptoms kept you from doing the kinds of things you would usually do, over the last week?




    8. How much did you think about your symptoms, over the last week?




    Quality of Life

    9. If you were to spend the rest of your life with your symptoms just the way they have been during the last week, how would you feel about that?







    In order to determine how effective your treatment is. we need to know how much pain is interfering in your normal activities. For the 7 areas listed below, please circle the number on the scale which describes the level of disability you have experienced in each area OVER THE PAST WEEK. A score of "0" means no disability at all, and a score of -10- indicates that all of the activities which you would normally do have been totally disrupted or prevented by your pain over the past week. Circle "0" if a category does not apply to you.

    Family/Nome Responsibilities: This category refers to activities related to the home or family. It includes chores or duties performed around the house (e.g. yard work,
    house cleaning) and errands or favors for other family members (e.g. driving the children to school.










    No Disability
    Mild
    Moderate
    Severe
    Total Disability
    Recreation: This category includes hobbies, sports, and other similar leisure time activities.










    No Disability
    Mild
    Moderate
    Severe
    Total Disability
    Social Activity: This category refers to activities which involve participation with friends and acquaintances other than family members. It includes parties, theater, concerts, dining out, and other social functions.










    No Disability
    Mild
    Moderate
    Severe
    Total Disability
    Occupation: This category refers to activities that are a part of or directly related to one's job. This includes non-paying jobs as well, such as housewife or volunteer worker.










    No Disability
    Mild
    Moderate
    Severe
    Total Disability
    Sexual Behavior: This category refers to the frequency and quality of one's sex life.










    No Disability
    Mild
    Moderate
    Severe
    Total Disability
    Self-Care: This category includes activities which involve personal maintenance and independent daily living (e.g. taking a shower, driving, getting dressed).










    No Disability
    Mild
    Moderate
    Severe
    Total Disability
    Life-Support Activity: This category refers to basic life-supporting behaviors such as eating and sleeping.










    No Disability
    Mild
    Moderate
    Severe
    Total Disability

    Urogenital Distress Inventory (UDI-6 Short Form): UDI-6


























    No= 0, Not at all= I, Somewhat= 2, Moderately= 3, Quite a bit= 4

    Add all scores and multiply by 6 then multiply by 25 for the scale score

    Missing items are dealt with by using the mean from the answered items only

    Higher score = higher disability

    Also see scoring of PFDI-20.

    Uebersax JS, Wyman JF, Shumaker SA. McClish DK, Fantl AJ. Short forms to assess life quality and symptom distress for urinary incontinence in women: the incontinence impact questionnaire and the urogenital distress inventory. Neurourol and Urodynam 1995;14:131-139.

    Grade A rating for symptoms of UI for women
    Donavan J. et al Symptom and quality of life assessment. In Incontinence vol I Basics and Evaluation eds Abrams P, Cardozo L, Khoury S, Wein A. Health Publications Ltd Paris France 2005.

    VULVAR PAIN FUNCTIONAL QUESTIONNAIRE (VQ)

    1. Because of my pelvic pain




    2. My pelvic pain





    3. My pelvic pain





    4. Because of pain pills I take for my pelvic pain





    5. Because of my pelvic pain




    6. Because of my pelvic pain




    7. Because of my pelvic pain




    8. Because of my pelvic pain




    9. Because of my pelvic pain