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  • If you are in the POPOUT Trial, please complete this form, about 1 yr after the birth of your baby.

    (If it is more than 12 months after the birth of your baby, we would appreciate it if you could still complete this form)
  • 1. First letter of your first name *
    eg if your name is Mary Smith, type in 'M'
  • 2. First letter of your surname *
  • 3. The hospital where my baby was born *
  • 4. The date my baby was born
    MM
    /
    DD
    /
    YYYY
     
  • 5. Have you been well since discharge from hospital? *
  • 5a) If you answered 'no' to the last question, please describe:
  • 6. Have you gone to the doctor or hospital for problems with your health after your baby was born? *
  • 6a) If you answered 'yes' to the last question, please describe *
  • 7. Have you been admitted to hospital since the birth of your baby? *
  • New Field
  • 8. Have you had an operation since the birth of your baby? *
  • 8a) If you answered 'yes' to the last question, please describe
  • 9. Since the birth of your baby, have you felt significantly depressed or down? *
  • 9a) If you have felt depressed or down, have you seen a doctor about this?
  • 10. Have you started anti-depressant medications since the birth of your baby? *
  • 11. Has your baby been well since discharge from hospital? *
  • 11a) If you answered 'no' to the last question, please describe:
  • 12. Have you ever breast fed your baby? *
  • 13. Are you currently breast feeding your baby? *
  • 14. How many weeks after the birth of the baby did you stop breast feeding? (answer if relevent)
  • 15. Have you taken your baby to the doctor or hospital for any health problems since birth? *
  • 15a) If yes, please describe
  • 16. Has your baby been admitted to hospital since birth? *
  • 16a) If yes, please describe
  • 16b) Has your baby had an operation? *
  • 16c) If yes, please describe

  • The next set of questions (17 - 28) ask for your views about your health.

    This information will help keep track of how you feel and how well you are able to do your usual activities. Please answer every question by marking one box. If you are unsure about how to answer, please give the best answer you can.
  • This information will help keep track of how you feel and how well you are able to do your usual act *
    Excellent
    Very good
    Good
    Fair
    Poor
    If you are unsure about these questions, please give the best answer you can.

  • The following items are about activities you might do during a typical day.

    Does your health limit you in these activities? If so, how much? ...
  • 18. Moderate activities such as moving a table, pushing a vacuum cleaner, bowling or playing golf *
    Yes, limited a lot
    Yes, limited a little
    No, not limited at all
  • 19. Climbing several flights of stairs *
    Yes, limited a lot
    Yes, limited a little
    No, not limited at all

  • During the past month:

    Have you had any of the following problems with your work or other regular daily activities AS A RESULT OF YOUR PHYSICAL HEALTH? ...
  • 20. Accomplished less than you would like? *
    Yes
    No
  • 21. Were limited in the kind of work or other physical activities? *
    Yes
    No

  • During the past month :

    Have you had any of the following problems with your work or other regular daily activities AS A RESULT OF ANY EMOTIONAL PROBLEMS (such as feeling depressed or anxious)? ...
  • 22. Accomplished less than you would like? *
    Yes
    No
  • 23. Didn't do work or other activities as carefully as usual? *
    Yes
    No

  • 24. During the past month,

  • how much did PAIN interfere with your normal work - both work outside the home and housework? *
    Not at all
    A little bit
    Moderately
    Quite a bit
    Extremely

  • These questions are about how you feel and how things have been with you DURING THE PAST MONTH. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time

  • During the past month,

  • 25. Have you felt calm and peaceful? *
    All of the time
    Most of the time
    A good bit of the time
    Some of the time
    A little of the time
    None of the time
  • 26. Did you have a lot of energy? *
    All of the time
    Most of the time
    A good bit of the time
    Some of the time
    A little of the time
    None of the time
  • 27. Have you felt downhearted and blue? *
    Most of the time
    A good bit of the time
    Some of the time
    A little of the time
    None of the time

  • 28. During the past month

    how much of the time has your PHYSICAL HEALTH OR EMOTIONAL PROBLEMS interfered with your social activities - like visiting with friends, relatives etc?
  • . *
    All of the time
    Most of the time
    Some of the time
    A little of the time
    None of the time
  • 29. In the past 24 hours have you experienced any pain? *
  • 29b) If you selected 'other' for the last question, please describe
  • Are you currently pregnant? *

  • ..

    THE FOLLOWING QUESTIONS WILL ASSIST US IN ASSESSING YOUR PELVIC FLOOR FUNCTION FOLLOWING THE RECENT BIRTH OF YOUR BABY.
  • How many times do you pass urine in the day? *
    up to 7
    between 8-10
    bewteen 11-15
    more than 15
  • How many times do you get up at night to pass urine? *
    0-1
    2
    3
    more than three
  • Do you wet the bed before you wake up at night? *
    never
    occasionally (less than once per week)
    frequently (once or more per week)
    always (every night)
  • Do you need to rush or hurry to pass urine when you get the urge? *
    can hold on
    occasionally have to rush (less than once per week)
    frequently have to rush (once or more per week)
    daily
  • Does urine leak when you rush or hurry to the toilet or you can't make it in time? *
    not at all
    occasionally (less than once per week)
    frequently (once or more per week)
    daily
  • Do you leak urine with coughing, sneezing, laughing or exercising? *
    not at all
    occasionally (less than once per week)
    frequently (more than once prer week)
    daily
  • Is your urinary stream (urine flow) weak, prolonged or slow? *
    never
    occasionally (less than once per week)
    frequently (once or more per week)
    daily
  • Do you have a feeling of incomplete bladder emptying? *
    never
    occasionally (less than once a week)
    frequently (once or more per week)
    daily
  • Do you strain to empty your bladder? *
    never
    occasionally (less than once a week)
    frequently (once or more per week)
    daily
  • Do you have to wear pads because of urinary linkage? *
    none/never
    as a precaution
    when exercising/during a cold
    daily
  • Do you limit your fluid intake to decrease urinary leakage? *
    never
    before going out
    moderately
    always
  • Do you have frequent bladder infections? *
    no
    1-3 per year
    4-12 per year
    more than one per month
  • Do you have pain in your bladder or urethra when you empty your bladder? *
    never
    occasionally (less than once a week)
    frequently (once or more than once a week)
    daily
  • Does the urine leakage affect your routine activities like recreation, socialising, sleeping, etc.? *
    not applicable (do not have urine leakage)
    not at all
    slightly
    moderately
    greatly
  • How much does your bladder problem bother you? *
    not applicable (do not have bladder problems)
    not at all
    slightly
    moderately
    greatly

  • Bowel Function

  • How often do you usually open your bowels? *
    every other day or daily
    less than every 3 days
    less than once a week
    more than once a day
  • How is the consistency of your usual stool? *
    soft
    firm
    hard (pebbles)
    watery
    variable
  • Do you have to strain a lot to empty your bowels? *
    never
    occasionally (less than once a week)
    frequently (once or more than once a week)
    daily
  • Do you use laxatives to empty your bowels? *
    never
    occasionally (less than once a week)
    frequently (once or more than once a week)
    daily
  • Do you feel constipated? *
    never
    occasionally (less than once a week)
    frequently (once or more than once a week)
    daily
  • When you get wind or flatus, can you control it or does wind leak? *
    never
    occasionally (less than once a week)
    frequently (once or more than once a week)
    daily
  • Do you get an overwhelming sense of urgency to empty your bowels? *
    never
    occasionally (less than once a week)
    frequently (once or more than once a week)
    daily
  • Do you leak watery stool when you don't mean to? *
    never
    occasionally (less than once a week)
    frequently (once or more than once a week)
    daily
  • Do you leak normal stool when you don't mean to? *
    never
    occasionally (less than once a week)
    frequently (once or more than once a week)
    daily
  • Do you have a feeling of incomplete bowel emptying? *
    never
    occasionally (less than once a week)
    frequently (once or more than once a week)
    daily
  • Do you have to use finger pressure to help empty your bowels? *
    never
    occasionally (less than once a week)
    frequently (once or more than once a week)
    daily
  • How much does your bowel problem bother you? *
    not applicable (do not have bowel problems)
    not at all
    slightly
    moderately
    greatly

  • Prolapse Symptoms

  • Do you have a sensation of tissue protrusion or a lump or bulging in your vagina? *
    never
    occasionally (less than once a week)
    frequently (once or more than once a week)
    daily
  • Do you experience vaginal presure or heaviness or a dragging sensation? *
    never
    occasionally (less than once a week)
    frequently (once or more than once a week)
    daily
  • Do you have to push back your prolapse in order to void? *
    not applicable (do not have prolapse)
    never
    occasionally (less than once a week)
    frequently (once or more than once a week)
    daily
  • Do you have to push back your prolapse to empty your bowels? *
    never
    occasionally (less than once a week)
    frequently (once or more than once a week)
    daily
  • How much does your prolapse bother you? *
    not applicable (do not have a prolapse)
    not at all
    slightly
    moderately
    greatly

  • Sexual Function

  • Are you sexually active?
    no
    less than once per week
    once or more per week
    daily or most days
  • If you are not sexually active, please tell us why:
    do not have a partner
    I am not interested
    my partner is unable
    vaginal dryness
    too painful
    embarassment due to the prolapse or incontinence
    other
  • Do you have sufficient natural vaginal lubrication during intercourse?
    yes
    no
  • During intercourse vaginal sensation is:
    normal/pleasant
    minimal
    painful
    none
  • Do you feel that your vagina is too loose or lax?
    never
    occasionally
    frequently
    always
  • Do you feel your vagina is too tight?
    never
    occasionally
    frequently
    always
  • Do you experience pain with sexual intercourse?
    never
    occasionally
    frequently
    always
  • Where does the pain during intercourse occur?
    not applicable (do not have pain)
    at the enterance to the vagina
    deep inside, in the pelvis
    both at the enterance and in the pelvis
  • Do you leak urine during sexual intercourse?
    never
    occasionally
    frequently
    always
  • How much do these sexual issues bother you?
    not applicable (do not have a sexual problem)
    not at all
    slightly
    moderately
    greatly