Patient Name: Date:

PFDI- SF20 1 Kathy Y. Jones, MD

If ye s , how much does it bother you?
Not at all Somewhat Moderately Quite a bit
Do you usually experience pressure in the lower abdomen?
YES N
Do you usually experience hea!iness or dullness in the lower
abdomen?
YES N
Do you usually ha!e a bul"e or somethin" #allin" out that you
can see or #ell in the !a"inal area?
YES N
Do you usually ha!e to push on the !a"ina or around the
rectum to ha!e a complete bowel mo!ement?
YES N
Do you usually experience a #eelin" o# incomplete bladder
emptyin"?
YES N
Do you e!er ha!e to push up in the !a"inal area with your
#in"ers to start or complete urination?
YES N
Do you #eel you need to strain too hard to ha!e a bowel
mo!ement?
YES N
Do you #eel you ha!e not completely emptied your bowels at
the end o# a bowel mo!ement?
YES N
Do you usually lose stool beyond your control i# your stool is
well #ormed?
YES N
Pelvic Floor Distress Inventory Questionnaire - Short Form 20
Please answer all o# the $uestions in the #ollowin" sur!ey% &hese $uestions will as' you i# you ha!e certain bowel, bladder or pel!ic symptoms
and i# you do how much they bother you% (nswer each $uestion by puttin" an in the appropriate box or boxes% )# you are unsure about how
to
answer, please "i!e the best answer you can% *hile answerin" these $uestions, please consider your symptoms o!er the last ! months"
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If yes, how much does it bother you?
Not at all Somewhat Moderately Quite a bit
Do you usually lose stool beyond your control i# you stool is
loose or li$uid?
YES N
Do you usually lose "as #rom the rectum beyond your
control?
YES N
Do you usually ha!e pain when you pass your stool?
YES N
Do you experience a stron" sense o# ur"ency and ha!e to
rush to the bathroom to ha!e a bowel mo!ement?
YES N
Does part o# your stool e!er pass throu"h the rectum and
bul"e outside durin" or a#ter a bowel mo!ement?
YES N
D you usually experience #re$uent urination
YES N
Do you usually experience urine lea'a"e associated with a
#eelin" o# ur"ency+ that is, a stron" sensation o# needin" to
"o to the bathroom?
YES N
Do you usually experience urine lea'a"e related to lau"hin",
cou"hin", or snee,in"-
YES N
Do you usually experience small amounts o# urine lea'a"e
.that is, drops/?
YES N
Do you usually experience di##iculty emptyin" your bladder?
YES N
Do you usually experience pain o# discom#ort in the lower
abdomen or "enital re"ion?
YES N
PFDI- SF20 0 Kathy Y. Jones, MD
Patient Name: Date:
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