Pelvic Floor Symptom Checklist

Would any of these tasks cause any of your symptoms?

If you can definitely do it, 100% of the time with no symptoms at all, leave blank. If there is even a small chance it would cause your symptoms, or you are not 100% confident it wouldn't cause symptoms, then tick it.

Movement Activities
1. Bending e.g. putting shoes/sock on/tying laces
2. Getting out of bed/off the sofa
3. Squatting/crouching
4. Walking on the flat short distances e.g. around a shop
5. Going up/down stairs
6. Low impact exercise e.g. Pilates/yoga/body balance
7. Walking to/from school/work/shops
8. Getting on and off the floor (bodyweight only)
9. Walking for exercise (increased time, distance and varying terrains)
10. Being on feet all day e.g. day trip, standing based job, but minimal lifting involved
Load Bearing Activities
11. Getting up from the floor holding a weight e.g. baby/toddler
12. Standing/lifting/carrying something light e.g. kettle/small baby (3-6kgs)
13. Standing/lifting/carrying a medium weight e.g. hoover, laundry basket, toddler, watering can, shopping bags/pushchair/car seat (7-15kgs)
14. Standing/lifting/carrying a heavy weight e.g. child, heavy plant pots, heavy boxes (15 kgs plus)
15. Pushing/pulling light items such as sweeping/mopping/raking
16. Pushing/pulling heavy items such as pushchairs/trolleys/dustbins/hoovers/suitcases
17. Being on feet all day (involving lifting) e.g. housewife, stay at home mum, shop assistant, carer, cleaner
18. Weightlifting/free-weights/gym machines
Impact Activities
19. Laughing
20. Coughing
21. Sneezing
22. Vomiting
23. Blowing nose
24. Playing in the park/garden with children
25. Running for a few steps, e.g. across the road, after a child
26. Running
27. Vigorous sports such as netball/football/tennis
28. Jumping e.g. star jumps, skipping
29. Trampoline/bouncy castle

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