How do symptoms or conditions relate to the following →→→

usually affect your ↓

Bladder or

Urine

Bowel or

Rectum

Vagina or

Pelvis

1) Ability to do household chores (cooking, housecleaning, laundry)?

□ Not at all

□ Somewhat

□ Moderately

□ Quite a bit

□ Not at all

□ Somewhat

□ Moderately

□ Quite a bit

□ Not at all

□ Somewhat

□ Moderately

□ Quite a bit

2) Ability to do physical activities such as walking, swimming, or other exercise?

□ Not at all

□ Somewhat

□ Moderately

□ Quite a bit

□ Not at all

□ Somewhat

□ Moderately

□ Quite a bit

□ Not at all

□ Somewhat

□ Moderately

□ Quite a bit

3) Entertainment activities such as going to a movie or concert?

□ Not at all

□ Somewhat

□ Moderately

□ Quite a bit

□ Not at all

□ Somewhat

□ Moderately

□ Quite a bit

□ Not at all

□ Somewhat

□ Moderately

□ Quite a bit

4) Ability to travel by car or bus for a distance greater than 30 minutes away from home?

□ Not at all

□ Somewhat

□ Moderately

□ Quite a bit

□ Not at all

□ Somewhat

□ Moderately

□ Quite a bit

□ Not at all

□ Somewhat

□ Moderately

□ Quite a bit

5) Participating in social activities outside your home?

□ Not at all

□ Somewhat

□ Moderately

□ Quite a bit

□ Not at all

□ Somewhat

□ Moderately

□ Quite a bit

□ Not at all

□ Somewhat

□ Moderately

□ Quite a bit

6) Emotional health (nervousness, depression, etc)?

□ Not at all

□ Somewhat

□ Moderately

□ Quite a bit

□ Not at all

□ Somewhat

□ Moderately

□ Quite a bit

□ Not at all

□ Somewhat

□ Moderately

□ Quite a bit

7) Feeling frustrated?

□ Not at all

□ Somewhat

□ Moderately

□ Quite a bit

□ Not at all

□ Somewhat

□ Moderately

□ Quite a bit

□ Not at all

□ Somewhat

□ Moderately

□ Quite a bit