Name:*

Date of Birth:*

Address:*

Postcode:*

Email:*

Tel:

What is your expected due date?:

How many weeks pregnant are you?:

Have you had your 12 week scan?:
YesNo

If not, please provide date of scan:

Telephone appointment or Near Me video appointment:
TelephoneNear Me

How problematic is it for you, because of your pelvic girdle pain, to:

1. Dress yourself
   Not at all (0)To a small extent (1)To some extent (2)To a large extent (3)N/A
2. Stand for less than 10 minutes
   Not at all (0)To a small extent (1)To some extent (2)To a large extent (3)N/A
3. Stand for more than 60 minutes
   Not at all (0)To a small extent (1)To some extent (2)To a large extent (3)N/A
4. Bend down
   Not at all (0)To a small extent (1)To some extent (2)To a large extent (3)N/A
5. Sit for less than 10 minutes
   Not at all (0)To a small extent (1)To some extent (2)To a large extent (3)N/A
6. Sit for more than 60 minutes
   Not at all (0)To a small extent (1)To some extent (2)To a large extent (3)N/A
7. Walk for less than 10 minutes
   Not at all (0)To a small extent (1)To some extent (2)To a large extent (3)N/A
8. Walk for more than 60 minutes
   Not at all (0)To a small extent (1)To some extent (2)To a large extent (3)N/A
9. Climb stairs
   Not at all (0)To a small extent (1)To some extent (2)To a large extent (3)N/A
10. Do housework
    Not at all (0)To a small extent (1)To some extent (2)To a large extent (3)N/A
11. Carry light objects
    Not at all (0)To a small extent (1)To some extent (2)To a large extent (3)N/A
12. Carry heavy objects
    Not at all (0)To a small extent (1)To some extent (2)To a large extent (3)N/A
13. Get up/sit down
    Not at all (0)To a small extent (1)To some extent (2)To a large extent (3)N/A
14. Push a shopping trolley
    Not at all (0)To a small extent (1)To some extent (2)To a large extent (3)N/A
15. Run
    Not at all (0)To a small extent (1)To some extent (2)To a large extent (3)N/A
16. Carry out sporting activities
    Not at all (0)To a small extent (1)To some extent (2)To a large extent (3)N/A
17. Lie down
    Not at all (0)To a small extent (1)To some extent (2)To a large extent (3)N/A
18. Roll over in bed
    Not at all (0)To a small extent (1)To some extent (2)To a large extent (3)N/A
19. Have a normal sex life
    Not at all (0)To a small extent (1)To some extent (2)To a large extent (3)N/A
20. Push something with one foot
    Not at all (0)To a small extent (1)To some extent (2)To a large extent (3)N/A

How much pain do you experience:

1. In the morning
   None (0)Some (1)Moderate (2)Considerable (3)
2. In the evening
   None (0)Some (1)Moderate (2)Considerable (3)

To what extent, because of PGP:

1. Has your leg/have your legs given way?
   Not at all (0)To a small extent (1)To some extent (2)To a large extent (3)
2. Do you do things more slowly?
   Not at all (0)To a small extent (1)To some extent (2)To a large extent (3)
3. Is your sleep interrupted?
   Not at all (0)To a small extent (1)To some extent (2)To a large extent (3)

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