Intake Questionnaire for Pelvic Pain Clinic

INTAKE QUESTIONNAIRE FOR PELVIC PAIN PATIENTS

First Name *

Last Name *

Date of Birth *

Email Address *

1. What is the pelvic issue that bothers you the most? *

2. What are the main things you would like to achieve or discuss at the Pelvic Pain & Endometriosis Clinic? *

Your tests

Please arrange copies of your most recent or most important results, reports and specialist letters. Bring them with you or email them prior.

3. Please list any relevant tests you have done and the main result, if known (eg Ultrasound, CT, MRI)

Your operations

4. Please list any operations you have had, the year they were done, and how long they helped your pain for, if at all.

Your medications

5. Which medications or supplements do you take for your pelvic symptoms? *

Your symptoms

7. How many times in the last 12 months have you attended the Emergency Department with pelvic pain related issues? *

Your team

8. Do you see a specific GP or clinic. Which one? *

9. Do you see a Pelvic physiotherapist. Which one? *

10. Do you see a Gynaecologist. Which one? *

11. Anyone else to support your pelvic pain or endo management? Please list. *

12. Do you have a GP Management Plan/ Chronic Disease Care Plan already? *

Yes No

Your permission to use this data for research

It is possible that we may wish to use the information in this questionnaire anonymously in the future for research purposes. We will only do this with your consent. Please note that any of your personal details would be removed from this record before it was used for research and you would not be identified in any way. Whether you tick yes or no in the boxes below will not affect the way we care for you, or your relationship with us.

Please tick a box *

Yes, I agree to this information being used anonymously for research No, I do not agree to this information being used anonymously for research

Thank you very much for taking the time to complete this questionnaire.

We look forward to seeing you at your visit and hope to make a real difference to your pain.

END OF QUESTIONNAIRE